Predictors of Stillbirths Among Post- Delivery Mothers in Pwani Region

The University of Dodoma University of Dodoma Institutional Repository http://repository.udom.ac.tz

Health Sciences Master Dissertations

2020 Predictors of stillbirths among post- delivery mothers in Pwani region.

Simtowe, Predicanda Mzurikwao

The University of Dodoma

Simtowe, P. M. (2020). Predictors of stillbirths among post- delivery mothers in Pwani region (Master dissertation). The University of Dodoma, Dodoma. http://hdl.handle.net/20.500.12661/2844 Downloaded from UDOM Institutional Repository at The University of Dodoma, an open access institutional repository. PREDICTORS OF STILLBIRTHS AMONG POST- DELIVERY MOTHERS IN PWANI REGION

PREDICANDA MZURIKWAO SIMTOWE

MASTER OF SCIENCE IN MIDWIFERY THE UNIVERSITY OF DODOMA COLLEGE OF HEALTH

DECEMBER, 2020 PREDICTORS OF STILLBIRTHS AMONG POST-DELIVERY MOTHERS IN PWANI REGION

PREDICANDA MZURIKWAO SIMTOWE

A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE DEGREE OF MASTERS OF SCIENCE IN MIDWIFERY

THE UNIVERSITY OF DODOMA COLLEGE OF HEALTH DECEMBER, 2020 DECLARATION AND COPY RIGHT

I, Predicanda Mzurikwao Simtowe, declare that this dissertation is my original work and that it has not been presented and will not be presented elsewhere in a similar way for either award or as a research project.

No part of this dissertation may be reproduced, stored in any retrieval system, or transmitted in any form or by any means without prior written permission of the author or the University of Dodoma. If transformed for publication in any other format shall be acknowledged that, “this work has been submitted for degree award at the University of Dodoma”.

CERTIFICATION

The undersigned certify that they have read and hereby recommend for acceptance by the University of Dodoma thesis/dissertation entitled “Predictors of stillbirths among post-delivery mothers in Pwani Region” in fulfillments of the requirements for the Degree of Masters of Science in Midwifery of the University of Dodoma.

Dr Secilia K. Ng‟weshemi

(Supervisor)

ACKNOWLEDGMENTS

First I would like to thank God the Almighty, for giving me this opportunity and strength, which enabled me to complete this study. I am very grateful to my supervisors Dr. Secilia K. Ng‟weshemi for her exceptional support, constructive comments and guidance, from the beginning to the end of this dissertation. I would also sincerely express my deepest gratitude to my adored lovely husband Mr. Edwin Steven Alfred Nguma for his support, as well as the Regional Administrative Secretary Pwani for granting me a permission to collect data. Again, I would like to thank my family, Mzurikwao‟s family especially my mum Annastazia Mzurikwao and my sister Leticia as well as my children Nazareth, Maureen, and Paularose who missed my care while undertaking this study.

I would like to acknowledge and thank the Tanzania Ministry of Health for sponsoring the entire study and all research assistants and other staff, for their support during data collection and entry. Last but not least, I would like to thank all those who have responded to my questionnaires.

However, it should be noted that, any shortcomings on this research are entirely belong to me.

iii

DEDICATION

Dedicated to the compassionate souls of the silent babies at birth

ABSTRACT

Background: Stillbirth is a silent traumatic canker that is a major concern of various individuals, health institutions, and the country as a whole. All over the world researchers are fighting tooth and nail to unravel the mystery surrounding the high prevalence of stillbirths. This study was carried out in Pwani region with the aim of finding the predictors associated with stillbirth among post-delivery mothers. Methods: A matched case-control study with a ratio of 1:2, conducted in Pwani region from May to early of August 2020 of which 65 post-delivery mothers faced stillbirths (Cases), and 130 postdelivery mothers with live borns (Controls) were enrolled. Interviewer-administered questionnaires and documentary reviews were used for data collection. Data were analyzed by using SPSS version 20. Results: All post-delivery mothers were enrolled, including 65 post-delivery mothers with stillbirths, and 130 post-delivery mothers with live borns, during the study. Post-delivery with high parity above 4 para, and women with less access to antenatal care were at increased risk of stillbirth. Mothers who were anaemic during admission to labour ward were more likely to have stillbirth compared to those who were not anaemic (AOR=4.690, p value=0.000). Furthermore, post-delivery mothers, who had not received a dose of sulfadoxine pyrimethamine, malaria in pregnancy, folic acid intake were more likely to have stillbirths, compared to live births, stillbirths were more likely to be preterm (AOR=4.024 95%, p value= 0.001), and post-delivery mothers taken local herbs during pregnancy as association with stillbirths (AOR=4.738, p value=0.000). Fetal presentation none other than cephalic was associated with stillbirth (AOR=12.591, p value= 0.000), birth weight <2.5kgand >4kg, and cord around the neck (AOR=15.326, p value=0.000). In addition, Obstetric factors associated with stillbirths were observed as post- delivery mothers who were referred from another facility (AOR=17.716, p value=0.000), history of cord prolapse was relatively more likely to be associated with stillbirths (AOR=13.656, p value=0.001). Furthermore, post-delivery mothers with a history of early rupture of membrane (before labour) more likely to be associated with stillbirth compared with rupture of the membrane during labour (AOR=29.819, p value=0.000).

Conclusion: Based on the results of the study, Stillbirth rate is still existing in Pwani Region hence is a major concern, appeared to be mostly associated with maternal factors, fetal factors, and obstetric factors. Recommendation; Improve uptake of ANC among pregnant mothers and reproductive age, empowering girls to prevent teenage pregnancy as stated by Sustainable development goal 5,improve health care provision and Hospital readiness for pregnancy emergencies. Key words: Stillbirth, Predictors, Pwani, Post delivery mother, Tanzania

TABLE OF CONTENTS DECLARATION AND COPY RIGHT ...... i CERTIFICATION ...... ii ACKNOWLEDGMENTS ...... iii DEDICATION ...... iv ABSTRACT ...... v TABLE OF CONTENTS ...... vii LIST OF TABLES ...... x LIST OF FIGURES ...... xi LIST OF APPENDEX ...... xii LIST OF ABBREVIATIONS AND ACRONYMS ...... xiii OPERATIONAL DEFINITIONS ...... xv

CHAPTER ONE ...... 1 1.0 INTRODUCTION ...... 1 1.1 Background information ...... 1 1.2 Statement of the problem ...... 4 1.3 Study Objectives ...... 5 1.3.1 Broad Objectives ...... 5 1.3.2 Specific Objectives ...... 5 1.4 Study Questions ...... 5 1.5 Significance Of the Study ...... 5

CHAPTER TWO ...... 7 2.0 LITERATURE REVIEW ...... 7 2.1 Overview of the chapter ...... 7 2.2 Theoretical Literature Review...... 7 2.2.1 Triple Risk Model ...... 7 2.2.2 Conceptual Model for Causal Pathways to Stillbirths ...... 9 2.3 Empirical Review ...... 9 2.3.1 Socio-demographic characteristics associated with stillbirths ...... 10 2.3.2 Maternal Factors...... 10 2.3.3 Fetal Factors ...... 14 2.3.4 Obstetric Factors ...... 14

vii

2.4 Conceptual framework ...... 16

CHAPTER THREE ...... 18 3.0 RESEARCH METHODOLOGY ...... 18 3.1 Study Area ...... 18 3.2. Study Design ...... 19 3.3 Study Population ...... 20 3.3.1 Definition of Case and Control ...... 21 3.3.2 Inclusion Criteria for cases...... 21 3.3.3 Exclusion Criteria cases ...... 21 3.3.4 Inclusion Criteria for controls ...... 21 3.3.5 Exclusion Criteria for controls ...... 21 3.4 Sample Size and Sampling ...... 21 3.4.1 Sample Size ...... 21 3.4.2 Sampling Technique...... 22 3.5 Data Collection Methods 23 3.6 Data Collection Tools – Instruments...... 24 3.7 Validity ...... 24 3.8 Instruments reliability ...... 24 3.9 Definition of variables...... 24 3.9.1 Dependent variables ...... 24 3.9.2 Independent variable ...... 24 3.10 Measurements of Variables ...... 25 3.11 Data Analysis ...... 25 3.12 Ethical consideration ...... 26

CHAPTER FOUR ...... 28 4.0 RESULTS AND DISCUSSION ...... 28 4.1 RESULTS ...... 28 4.1.1 Social Demographic Characteristics of the Study Participants ...... 28 4.1.2 Maternal Clinical Characteristics of the Study Participants with Relationship to Stillbirth …………………………………………………………………………….29

viii

4.1.3 Fetal Clinical Characteristics Contributing to Stillbirth ...... 32 4.1.4 Frequency Distribution of Obstetric Factors Contributing to Stillbirths...... 33

4.1.5 Relationship between Social Demographic characteristics and Stillbirths among post-delivery mothers in Pwani Region …………………………………………… 34

4.1.6 Relationship between Maternal Factors and Stillbirths among post-delivery Mothers in Pwani Region ...... 35 4.1.7 Relationship between Fetal Factors and Stillbirths among Post-Delivery Mothers in Pwani Region ...... 37 4.1.8 Relationship between Obstetric Factors on Stillbirths among Post-Delivery Mothers in Pwani Region ...... 38 4.1.9 Logistic Regression on the Maternal Predictors of Stillbirths among Post- Delivery Mothers at Pwani Region ...... 38 4.2 DISCUSSION ...... 41 4.2.1 The Influence of Maternal Factors on Stillbirths among Post-Delivery Mothers in Pwani Region ...... 41 4.2.2 The Influence of the Fetal Factors on Stillbirths among post-delivery mothers in Pwani Region ...... 44 4.2.3 The Influence of Obstetric Factors on Stillbirths among post-delivery mothers in Pwani Region ...... 46 4.2.4 Strength of the study ...... 48 4.2.5 Limitation of the study ...... 48

CHAPTER FIVE ...... 49 5.0 CONCLUSION AND RECOMMENDETION...... 49 5.1 Conclusion ...... 49 5.2 Recommendetion...... 49 5.3 Study dissemination ...... 50 5.4 Suggestion for further study ...... 50 REFERENCES ...... 51

LIST OF TABLES Table 1: Frequency distributions of Social demographic characteristic of study participants ...... 29 Table 2: Frequency distribution of maternal factors contributing to stillbirth ...... 31 Table 3: Frequency distribution of Fetal factors contributing to stillbirth ...... 32 Table 4: Frequency Distribution of Obstetric Factors on Stillbirth ...... 33 Table 5 Relationship between Social Demographic characteristic and stillbirths among post-delivery mothers in Pwani Region ...... 34 Table 6: Relationship between maternal factors and stillbirths among post-delivery mothers in Pwani Region ...... 36 Table 7: Relationship between Fetal factors and stillbirths among post-delivery mothers in Pwani Region ...... 37 Table 8: Relationship between obstetric factors on stillbirths among post- Delivery mothers in Pwani Region ...... 38 Table 9: Logistic Regression on the Maternal predictors, the Fetal Predictors, and Obstetric Predictors of stillbirths among post-delivery mothers at Pwani Region ...... 39

LIST OF FIGURES

Figure 1: Triple risk model ...... 8 Figure 2: Conceptual Framework ...... 17 Figure 3: Pwani Region Map Showing District Councils ...... 20

LIST OF APPENDEX

Appendix 1 : Consent form (English) ...... 59 Appendix 2: Form Ya Ridhaa Ya Utafiti wa Kuangalia Viashiria Vya Watoto Wachanga Kuzaliwa Wafu (Kiswahili) ...... 62 Appendix 3: Questionnaire (ENGLISH) ...... 65 Appendix 4: Dodoso (Kiswahili) ...... 73 Appendix 5: Letter for Ethical clearance from Dodoma University bord of Research ...... 81 Appendix 6: Request for research clearance ...... 82 Appendix 7: Letter from Regional Administrative Secretary (RAS) for permition to conduct research in Pwani region ...... 83

xii

LIST OF ABBREVIATIONS AND ACRONYMS

AIDS Acquired Immunodeficiency Syndrome

ANC Antenatal care

AOR Adjusted odd ratio

APH Antepartum Hemorrhage

BEMONC Basic Emergence Obstetric and Neonate Care

BMI Body Mass Index

C/S Caesarian Section

CD4 Cluster of Differentiation 4

CEMONC Comprehensive Emergence Obstetric and Neonate Care

CO Carbon Monoxide

FBO Faith Based Organization

FHR Fetal Heart Rate

GA Gestation Age

HB Hemoglobin

HIV Human Immunodeficiency Virus

IUGR Intrauterine Growth Restriction

LMIC Low and middle income country

MOHCDGEC Ministry of Health Community Development Gender Elderly and Children.

xiii

NBS National Bureau of statistics

NHDSS Navrongo Health Data Surveillance system

PPROM Preterm Premature Rupture of Membrane

PROM Premature Rupture of Membrane

RAS Region Administrative Secretary

SBR Stillbirth Rates

SDG Sustainable Development Goal

SIDS Sudden Infant Death Syndrome

SPSS statistical package for social science

SVD Spontaneous Vertex Delivery

TDHS-MIS Tanzania Demographic Health Survey Malaria Indicator Survey

UCP Umbilical Cord Prolapse

VDRL Venereal Disease Research Laboratory

WHO World Health Organization

xiv

OPERATIONAL DEFINITIONS

Live born A baby born alive (Apga score ≥ 7 in one minute and 10 in 5 minutes) with birth weight ≥1000 or gestation age of 28 weeks.

Stillbirth A baby born dead (without spontaneous respiration or heartbeat) with 1000 grams birth weight or great or equal to gestation of 28 weeks.

CHAPTER ONE

1.0 INTRODUCTION

1.1 Background information

Stillbirth indicates a fetus born after 28 completed weeks of pregnancy without a spontaneous breath or heartbeat. It is equivalent to intrauterine fetal demise in which no fetal heartbeat is detected after 28weeks of gestation. (Liu et al., 2014). In low- income countries, the gestational age of 28 weeks or birth weight of 1000g is often selected as the lower limit of viability (Nieminen, Mannevaara, and Fagerström 2011; WHO, 2005). Stillbirths can be classified based on time of occurrence or physical appearance as it could either be antepartum or intrapartum. Antepartum stillbirths are also known as macerated or intra-uterine stillbirths, it occurs if the baby dies in the womb before the onset of labor, usually more than 12 hours prior to delivery. Intrapartum stillbirths are also referred to as fresh stillbirths, it occurs if the baby dies after the onset of labor, usually less than 12 hours prior to delivery (Chuwa et al. 2017).

Every stillbirth is a tragedy and a potential life lost, which bring about psycho-social effects for parents, including anxiety, long-term depression, post-traumatic stress disorder, and stigmatization (Aminu et al. 2014), Sadly, women who have experienced a stillbirth are more likely to experience this again in subsequent pregnancies(Christou, Dibley, and Raynes-greenow 2017; Kupka et al., 2009), most of these deaths can be prevented (Lawn et al., 2011).

Stillbirths are the most frequent adverse pregnancy outcomes. The currently available statistics show that globally, 2.6 million stillbirths occur each year and range from 2.4 – 3.0 million (Chuwa et al., 2017). These estimates are equal to a 19% reduction in the number of stillbirths since 2000 (McClure et al. 2018; WHO 2012). The problem is acute in developing countries where the rate of stillbirth is ten times compared to countries with developed countries where the rate is 3 to 5/1000 live births (Mcclure &Goldenberg 2014).

Sub-Sahara Africa is mainly affected by stillbirth (WHO, 2015). This region is estimated to have 880, 000 stillbirths annually. 60% of these stillbirths are experienced by poor and rural families (Aminu et al., 2014; WHO, 2015). Tanzania

1 alone has a record of stillbirths around 47,000 each year; this corresponds to a rate of 26 per 1000 births; thus making it the ninth highest rate in the world (Lawn et al., 2011).

Traditionally, the causes of stillbirth have been differentiated in maternal, fetal, placental, and external factors (Tavares et al., 2016). The most common cause is a maternal infection due to bacteria organisms, other infectious, like Malaria, syphilis, and HIV contributes to stillbirth (Tavares et al., 2016). Other maternal conditions that contribute to stillbirth occur during antepartum are thyroid abnormalities, diabetes mellitus, hypertensive disorders, renal disease, systemic lupus erythematosus, and sickle cell disease (Stormdal Bring et al., 2014). Nutritional deficiencies and Anemia in women are also the universal cause of stillbirth or other adverse pregnancies in developing countries (McClure et al., 2018).

The fetal causes include intrauterine fetal growth restriction (IUGR) which is placental dysfunction that may be associated with various mother‟s conditions as it is described above (Tavares et al., 2016). Other causes are congenital anomalies, multiple gestations, post maturity and genetic abnormalities, fetal infection, (Tavares et al., 2016). Other causes include premature rupture of membrane, placental abruption, Vasa Previa, vascular malformations, chorioamnionitis, and umbilical cord accidents like occult cord, true knots, or abnormal placement (Stormdal Bring et al., 2014). Moreover, external causes, like antepartum maternal trauma or delivery/labor incidents such as obstetric trauma and birth asphyxia, deaths are frequent where modern obstetric care is not available (Tavares et al., 2016). In developing countries asphyxia cause around 7 deaths per 1000 births compared to developed countries where the rate is less than one per 1000 births (WHO, 2006).

Systematic reviews have confirmed age related risk factors for stillbirth, young age or old maternal age; primigravida have a high risk of stillbirth than multiparous mothers across all ages, of these nulliparous women aged 35 years and older have been shown to have 3.3 fold increase in the risk of unexplained fetal death than with women younger than 35 years of age, the association of maternal age 40 years and older is 3.7 higher the risk (Tavares et al., 2016).

Other factors are maternal smoking either passive or active smoking, alcohol intake, body mass index (BMI) ≥30, drug abuse especially use cocaine, cannabis, and multi

2 fetal gestation, which is significantly high especially as observed in monochorionic twins than in dichorionic (Tavares et al., 2016). The global rate of stillbirths is approximately 67% occurs in rural families, where cesarean sections are much lower than that for urban and skilled birth attendance are little before 24 weeks of gestation (Tavares et al., 2016).

Accessibility of good delivery services can prove the good outcome of the pregnancy, as it was observed in a study stated as in a presence of skilled attendants during the process of delivery can lead to a decrease in the number of stillbirths (Tavares et al., 2016). Interventions to the problem of stillbirths would contribute to improved maternal and child survival (Tilahun & Assefa, 2017). This can be achieved by the early recognition of risk factors for stillbirth and suitable antenatal management to be taken to improve pregnancy outcomes and reduce avoidable stillbirth (National Bureau of Statistics [NBS], 2015/2016). Different approaches have been applied by the Government of Tanzania to increase access to antenatal care services, including the provision of free ANC services (Gross et al., 2012). Almost all women (98%) aged 15-49 receive antenatal care (ANC) from skilled providers when they visit clinics during their pregnancy time (National Bureau of Statistics [NBS], 2015/2016). Despite a good spread of antenatal services, a single pregnant woman out of four make their antenatal visit within 12weeks as per guideline and only 51% attend antenatal clinic four times (National Bureau of Statistics [NBS], 2015/2016). The number of pregnant mothers receiving care at least four times has raised from 43% in 2010 to 51% in 2015 (National Bureau of Statistics [NBS], 2015/2016 ). Also, eight in ten women took blood builder supplementation and 88% of them were received two doses of tetanus injections. 87 % and 60%, and 71% have measured HB to rule out anemia, investigation for UTI and measured blood pressure respectively (National Bureau of Statistics [NBS] n.d.).

What gives hope is that stillbirth deaths can be avoided (Lawn et al. 2011). However,by increasing compliance with appropriate interventions like adequate fetal heart rate monitoring and partogram use, the risk of intrapartum stillbirth might be reduced(Kc et al. 2016). However, there is a general lack of information on why these deaths continue today, this raises some concerns as to why they occur when there are many ANC services accessible to the majority of pregnant women (Baqui et al. 2017).

To address the gap well designed plans, (approach) should be developed these may include but not limited to the aggressive ongoing audit process, proper ANC follow up, treatment of antepartum infections, provision of supplementation and iron tablets, proper monitoring progress of labour to capacitate the health care providers to address/advocate the condition that results in stillbirths, other interventions to prevent the death include diagnose or treat those conditions in the home clinic, and hospital as pointed earlier these interventions can be applied when the cause of the death is well known under this context, thus the proposed project directed to look on the predictors associated to stillbirths among post-delivery mothers in Pwani region.

1.2 Statement of the problem

The prevalence of stillbirth in Tanzania is inacceptable high and the causes are not well documented to inform policy actions. About 47,000 stillbirths occurred every year, which was equal to a rate of 26 per 1000 births (Lawn et al., 2011) stillbirths contributed to about 36% of the total perinatal deaths in the eastern zone, Pwani included (National Bureau of Statistics [NBS] n.d.). Furthermore, the report from local data DHIS, the number of stillbirth in Pwani Region is about 513, 475, and 545 stillbirths occurred in 2017, 2018, and 2019 respectively.

A baby born dead is an event explaining that one‟s life is lost and causing great suffering and distress to family and bring about stigmatization among the community (Aminu et al., 2014) sadly stillbirth is repetitive(Jolly et al., 2010; Kupka et al., 2009; Liu et al., 2014), however, fetal deaths can be avoided (Lawn et al., 2011) but this depends on the literature existing about the predictors of stillbirths, therefore there are need to understand the predictors of stillbirths to inform for the appropriate intervention (Islam et al., 2011). Never the less the predictors of stillbirths are not well recognized (Baqui et al., 2012).

However, it is important to acknowledge the efforts that are already available by the Government of Tanzania. There has been increased access to free ANC services (Gross et al., 2012). Further, health care providers have been trained to address the importance of ANC, there are BEmONC and CEmONC services introduced to reduce maternal complications during delivery which could complicate the wellbeing of the baby (Plotkin et al., 2018).

Despite these efforts, the problem still exists at an increased rate in the country, Pwani inclusive. The predictors of stillbirths related to maternal factors, fetal factors, and obstetric factors are under-published in Tanzania, especially in Pwani region. The aim of the project is, therefore, to assess the causes and predictors for stillbirths among post-delivery mothers in Pwani region.

1.3 Study Objectives

1.3.1 Broad Objectives

To assess the predictors of stillbirths among post delivery mothers at Pwani Region.

1.3.2 Specific Objectives

i. To determine the influence of maternal factors on stillbirths among post- delivery mothers in Pwani Region

ii. To determine the influence of the fetal factors on stillbirths among post- delivery mothers in Pwani Region

iii. To determine the influence of obstetric factors on stillbirths among post- delivery mothers in Pwani Region

1.4 Study Questions

i. What is the influence of maternal factors on stillbirths among post-delivery mothers in Pwani Region?

ii. What is the influence of the fetal factors on stillbirths among post-delivery mothers in Pwani Region?

iii. What is the influence of obstetric factors on stillbirths among post-delivery mothers in Pwani Region?

1.5 Significance Of the Study

The results of the study will partly contribute to the global targets of reducing stillbirths. One of the global targets is to end avoidable maternal and newborn deaths and stillbirths. All countries are called by the global targets to end stillbirth rates nationally (SBRs) of less than 12 stillbirths per 1000 births by 2030 (WHO, 2014).

Besides, the study was laid in knowledge to the very few published literature on the predictors of stillbirths in Pwani region; thus, the study seeks to provide evidence based information to develop new strategies to reduce the rate of stillbirths in Pwani Region. Furthermore, the findings of the study formed a basis for the amendment of the existing national policy to reduce the prevalence of stillbirths and as well raise the community awareness on the predictors of stillbirths.

CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 Overview of the chapter

This chapter describes the review of related literature on the study to look the predictors and associated factors of stillbirth on what is already done. The chapter, consists of three parts: Theoretical review, empirical review and conceptual framework.

2.2 Theoretical Literature Review

In this part of the literature, the discussion was based on two theories, namely the Triple Risk Model, and Causal Pathway Theory whose concepts describe how the outcome is affected by several factors.

2.2.1 Triple Risk Model

The model was developed in 1950s, and became accepted in the medical and scientific establishment to find out what caused the unexpected child death. Two international conferences were organized in Seattle in 1963 and 1969 to address what was known about the etiology of SIDS. This model, first devised in 1972 and later on revised in 1994 by Filiano and Kinney. It is still widely used in assisting in the conceptualizing and understanding of the sudden deaths in the infancy stage (Goldwater and Bettelheim 2015).

The Triple Risk Model for unexplained late stillbirths tries to explain that fetal loss, especially the late stillbirth (Gestational age ≥28 weeks) is a combination of more than one characteristic, maternal and fetal characteristic which are shown in the conceptual framework of a Triple Risk Model:

Figure 1: Triple risk model

Source: Triple risk factor from (Warland & Mitchell, 2014)

As the diagram illustrates, unexplained fetal deaths can be analyzed using multiple parameters. These multiple parameters help in explaining the possible pathogenetic mechanisms leading to death (Warland & Mitchell, 2014). The concepts of the theory, explains that stillbirths are a devastating event. Unexplained stillbirth is problematic to study because of the paucity of clues. Furthermore, there is probable heterogeneity of many of the antecedent causes. However, in this study the model concepts applied as we observed that maternal characteristics like maternal age and maternal education level (younger age ≤ 20 years depend on male partner decision or low education/ non educated fail to make an immediate judgement and take appropriate action) can contribute to some delays in seeking care, and maternal age: very early or advanced maternal age; young age below 20 years and older than 35 years have been shown to have a 3.3-fold increase in the risk of unexplained fetal death compared with women younger than 35 years of age (Aminu et al., 2019; Tavares et al., 2016), thus, the model explains the multiple parameters that contribute to the outcome.

2.2.2 Conceptual Model for Causal Pathways to Stillbirths

The cause of stillbirth is multifactorial, and the relationships between stillbirth and its many risk factors are complex. Many systematic reviews and conceptual models already highlight the biological factors in great detail (Menezes et al., 2009, Reinebrant et al., 2017). While these proximal biological factors are direct causes of stillbirth, distal factors – social, behavioral, and environmental – also contribute to the risk of stillbirth through multiple causal pathways. Such factors may have a direct effect, be mediated by other factors, or act as a proxy for some other unknown influence. For example, “inadequate antenatal care” could be measuring insufficient screening for preventable conditions, a lack of funding/resources, or acting as a proxy for social inequalities that affect healthcare access. However, these more distal factors, (and their related interventions) attract less attention from researchers (Yakoob et al., 2009). Often, data for these distal determinants, such as poverty and inequity are not available to count the risk (Seale et al., 2017).

The model of cause built the assumption and practice observation in literature which considers all possible pathways as well as studies using structure or multilevel models (Warland &Mitchell, 2014) each of which treated stillbirth or perinatal mortality as the primary outcome. The model includes several broad determinants which have a direct and indirect impact or both on stillbirth. These are used to show strong statistical associations between determinants and suggest the causal link. Social economic position: Education level, occupation and income, features of marital status and area deprivation. The maternal age is more directly involved than other demographic characteristics due to biological mechanisms that lead to stillbirth

2.3 Empirical Review

The empirical review describes the already done literature from giants of researchers concerning stillbirths and comes up with the solutions to reduce the burden of the problem. The literature reviewed here is based on the predictors and associated factors mention in the project; i.e. social demographic factors, maternal factors, fetal factors, and obstetric factors.

2.3.1 Socio-demographic characteristics associated with stillbirths

Age is one of the risk factors of stillbirth in many countries. A systematic literature review done and middle income countries revealed that advanced maternal age (> 35 years) and young age (< 20 years) were associated with Stillbirths. For instance, in china, the rate of stillbirths was higher in younger age compared to the older ones (5.1% and 0.9% respectively) and also identified that prim parity and parity > 5 contributing risk factors to stillbirth (Aminu et al., 2014). Furthermore, the study done in Napal (2019) concluded that the rate of stillbirths of 5.5% of entire pregnant women with advanced maternal age, smoking behavior, and with an informal education and none employed, had experienced stillbirths, also the stillbirth was associated with economic status of the family, cooking fuel, and region of residency. Likewise, woman, who used relatively polluting cooking fuels had a higher risk of stillbirth compared to their counterparts (Bhusal et al., 2019).

The TDHS MIS (2015-2016) data shows that neonatal death rate is higher in women with younger age less than 20 years and the oldest women aged 40-49 and more frequent to urban resident compared to rural, which account for 47 and 37 per 1000 pregnancy respectively. It is thought that the younger women face pregnancy and delivery difficulties due to biological immaturity, in other hands older women may also experience age-related problems during pregnancy and delivery (National Bureau of Statistics [NBS] n.d.).

According to TDHS-MIS data, shows that 63% of pregnant women deliver at health facility compared to home delivery which is 36% and most of the home deliveries are women coming from poor families and with no education (National Bureau of Statistics [NBS] ). Despite all strategies still, there is a slow reduction of stillbirths.

2.3.2 Maternal Factors

This part includes the literature review concerning maternal characteristics which can be any existing condition like chronic hypertension, known diabetes or can be a condition related to index pregnancy, like eclampsia, gestational diabetes, and an explanation of how the conditions affect the pregnancy outcome. A study done by Badimsuguru in Tamale Ghana revealed that the low diastolic blood pressure of less than 80mmHg, particularly in late pregnancy, was significantly associated with stillbirth (AOR = 2.2, 95% CI 1.04 – 4.54). A similar observation was made in the

10 bivariate model (OR = 31, 95% CI 1.84 – 5.16). In the bivariate analysis, systolic blood pressure of = 99mmHg and diastolic blood pressure of < 80mmHg at registration had rise the risk of stillbirth compared to systolic blood pressure range of 100–139mmHg and diastolic blood pressure range of 80 – 85mmHg (Badimsuguru et al., 2016).

A population-based case-control study done in Chandigarh, India, the results shows that the rate of stillbirth was probable to be 16/1000 birth. Antepartum causes were more common compared to intrapartum causes (68%, 32% respectively). In addition, among maternal conditions, hypertension and chorioamnionitis (18.2% and 13.8% respectively) (Newtonraj et al., 2017).

A study that was done by Sujatha et al., (2017) on Risk factors for stillbirths with some references on a hospital based case control in Trivandrum, Chennai, India reported that maternal age was one of the major risk factor associated with stillbirths. In this study, 17% were in the high risk age group. These included 7% below 20 years, and 8% above 35 years. Another study that was done by Lucy et al. revealed that the highest no of fatal deaths occurred at the age of 35 years.

Miller HS et al. explored the occurrence of pre-eclampsia, fetal disproportion, preterm labour, contributory distribution, and contamination is high in teenage pregnancies. Whereas, more than 35 yr old mothers were revealed in other studies to have the risk of developing preeclampsia, diabetes, macrosomia, stillbirth and postpartum complications (Lakshmi et al., 2017). In a study that was done in Milan University Italy, a multi institutional new analysis study revealed that maternal smoking during pregnancy, nicotine and carbon monoxide (CO), its main combustion product, pass via the placenta in the fetal flow where they can reach concentrations even 4 times higher than those present in maternal blood, due to the poor metabolic capacity of the fetal liver. The significances can be several in the fetus one is stillbirth (Rovereto et al., 2019).

A systematic review was done on the studies conducted in lower and middle-income countries, Tanzania not exclusive, noted that maternal factors (8%–50%) i.e. syphilis, positive HIV status with insufficient CD4 count, Malaria and Diabetes mainly pretentious women. The fetal factors included inherited anomalies which were described to account for 2.1%–33.3% of stillbirths, placental causes (7.4%–42%),

11 asphyxia and birth trauma (3.1%–25%), umbilical problems (2.9%– 33.3%), and amniotic and uterine factors (6.5%–10.7%) (Aminu et al., 2014). Furthermore, one recent study that was conducted in Kilimanjaro Region noted maternal factors such as preeclampsia and placenta abruption and fetal factors, such as non-cephalic presentation and low birth weight were associated with stillbirths (Chuwa et al., 2017).

A systematic literature review of the causes of stillbirths in the low and middle- income countries done by Aminu et al., (2014) reported that the most common cause of stillbirth was maternal issues (8-50%), among them, being syphilis, Malaria, positive HIV status with low CD4 count, and diabetes (Aminu et al., 2014). placental causes (7.4–42%), and amniotic and uterine factors (6.5–10.7%) (Aminu et al., 2014).

The literature on stillbirths was a significant examination of the importance of stillbirths. One of the studies was done by Reddy et al. (2006) using population- based data for more than five million pregnancies in thirty-six American states from 2001 to 2002. These detectives described stillbirth risk by gestational week, subdivided according to maternal age. For all women, forty-one weeks‟ gestation was the period of greatest risk but stillbirth incidence seemed to begin increasing for all age groups earlier at approximately thirty-eight weeks. This finding agrees with preceding work by Hilder et al. 2006, and subsequent work by Bahtiyar et al. 2008. Hilder et al. showed a marked rise in stillbirth risk in the direction of a term; risk augmented six-fold between 37 and 43 weeks‟ gestation, from 0.35 per 1000 ongoing pregnancies to 2.12 per 1000 ongoing gravidities.

In the work by Reddy et al. and Bahtiyar et al., nevertheless, there is also evidence of interaction among and gestational age, maternal age, with older women having an extraordinarily sharper increase in stillbirth risk with progressing gestation than younger women. Reflecting on the general influence of this risk factor, (Gulmezoglu et al., 2015), in a systematic review strongminded that routine induction of labor among women at forty-one accomplished week gestation stemmed in a statistically significant decrease in total stillbirths.

Maternal health is thoroughly connected to the health newborn, and several risk factors for poor maternal health that linked to poor fetal outcomes. Two organized

12 reviews were done by Lawn et al. (Bhutta, Lassi, Blanc, & Donnay, 2010 & Di Mari et al., 2007 as cited by Aminu et al., 2014) who came up with some risk factors for the third trimester, poor maternal nutrition, stillbirth including adolescent or elderly pregnancy; grand multi-parity; such as low body mass index or severe anemia; maternal medical circumstances during pregnancy; such as tobacco, exposure to toxic substances, use of biomass for cooking or environmental toxins; and socioeconomic deprivation, i.e., poor access to healthcare services during pregnancy, either due financial barriers or insufficient access to data (Aminu et al., 2014).

The study done in South Africa (2017) revealed that antenatal care especially during the third trimester is very vital to pregnancy better outcomes as it shown that the increased risk of stillbirth after 6 weeks‟ absence of antenatal visits. Explained more than the estimate of 50% of stillbirths have maternal complications where making a correct timing and frequency appointments during the third trimester will help to identify the risk and handle it in an appropriate manner to prevent avoidable deaths (Lavin & Pattinson, 2017).

The other study was done to analyze the associations between maternal hemoglobin at the first visit and at 28 weeks with stillbirth and perinatal death, adjusting for 11 other risk factors. Results showed that 46% of the study population had anaemia (hemoglobin<110 g/l) at some point during their pregnancy.

The risk of stillbirth and perinatal death decreased linearly per unit increase in hemoglobin concentration at first visit (adjusted odds ratio [AOR] stillbirth= 0.70, 95% confidence interval [CI] 0.58–0.85, AOR perinatal death = 0.71, 95% CI 0.60– 0.84) and at 28 weeks (AOR stillbirth = 0.83, 95% CI 0.66–1.04; AOR perinatal death = 0.86, 95% CI 0.67–1.12). Compared with women with hemoglobin ≥110 g/l, the risk of stillbirth and perinatal death was five-fold, and three-fold higher in women with moderate-severe anaemia (hemoglobin <100 g/l) at the first visit and 28 weeks, respectively (Nair et al., 2017). However, a few studies exist in low-income countries that identify avoidable risk factors for intrapartum stillbirth, especially in settings where obstetric care is willingly existing (Jammeh, Vangen, and Sundby, 2010).

2.3.3 Fetal Factors

The study that was done in low and middle revenue countries reported that, in Belagavi India, the primary cause of stillbirths is related to congenital anomalies, which attribute to stillbirth for 19.6% rate and African site was 5% or less (McClure et al., 2018). The most shared cause of stillbirth related to fetal factors comprises congenital abnormalities which are reported to account for 2.1%–33.3% of asphyxia, stillbirths, and birth trauma (3.1%–25%), umbilical problems (2.9%–33.3%) (Aminu et al., 2014). The studies that were done in low- and middle-income countries revealed that obstetric problems during the intrapartum period, fetal malpresentation,

A nuchal cord or cord around the neck (CAN)) occurs when the umbilical cord becomes wrapped around the fetal neck 360 degrees. Nuchal cords are very common, the incidence of nuchal cord increases with advancing gestation from 12% at 24 to 26 weeks to 37% at term(Peesay, 2012). Most are not associated with perinatal morbidity and mortality. In some fetuses and newborns, Cord-Around-the Neck may cause problems, especially when the cord is tightly wrapped around the neck referred to as tight Cord around the Neck Syndrome. Umbilical cord compression due to tight Cord around the Neck may cause obstruction of blood flow first in thin walled umbilical vein, while infant‟s blood continues to be pumped out of baby through the thicker walled umbilical arteries thus causing hypovolemia and hypotension resulting in acidosis, anemia and mild respiratory distress may occur (Peesay, 2012).

2.3.4 Obstetric Factors

Many studies reported that Obstetric circumstances are among the causes and risk factors of stillbirth (Liu et al., 2014). Placenta abruption is among the causes of stillbirths which 9-15.2% of the total stillbirths, rupture of the amnion, and chorion prior to the gestational age of 37 weeks (PPROM) and premature rupture of membranes (PROM) account for 0.8%, 15- 43% of total stillbirths in the 2nd trimester respectively. The rate of stillbirths in PPROM is decreased to be 4.5% if managed expectantly at the same gestational age (Liu et al. 2014). Another study was done in Stockholm, Sweden on the causes of stillbirth at dissimilar gestational ages in single tone pregnancies recommended that placenta abruption attributed 20.3% of stillbirths and umbilical cord complications added to 16.1% (Stormdal et al., 2014).

In-depth analysis of all stillbirths was done to rule out the causation for 10 years in a busy maternity unit situated in a socio-economically urban area, with an emphasis on overlapping pathology, the results show that overlapping pathology was identified in 43% of stillbirths. Infection, IUGR, and abruption were the most important single cause of stillbirth (Wijs, Leemaqz, & Dekker, 2016). Bayou and Berhan, (2012) found that among obstetric factors, antepartum haemorrhage, hypertensive disorders, and obstructed labour as independent risk factors associated with stillbirths (Bayou and Berhan 2012).

Nahar et al., (2012) identified preterm delivery, prolonged labour, and failure of labour progress as important obstetric risk factors of stillbirth (Engmann et al., 2012). Further, a study conducted to compute perinatal mortality in the Upper East Region of Ghana. They studied data collected on the Navrongo Health Data Surveillance system (NHDSS) database from January 2002 to December 2008. Most stillbirths (71%) were 31 weeks or a few weeks (Badimsuguru et al., 2016). The study done in the low and middle-income republics, identified probable causes of stillbirths, were maternal infection as the most cause. In Democratic Republic of Congo, maternal infection paid 55.7% of stillbirth, while in Nagpur, India it was 2.6%. In addition, antepartum hemorrhage and preeclampsia/eclampsia contributed to 19.2% and 18.4% in that order (McClure et al., 2018).

Other study was done in Sweden, on the reasons for stillbirth at various gestational ages in singleton pregnancies, done by Hanna Stomadal et al., 2014, a cohort study classified stillbirth in preterm gestation 22+0-36+6 and term/post term gestation 37+0- 40+6 (Stormdal et al., 2014). The main outcome measure, causes of stillbirth at various gestational ages were a high fraction of placental abruption and preeclampsia/hypertension were seen in preterm stillbirths compared to post-term stillbirths, which instead had a higher proportion of umbilical cord problems and infection. Infection was more mutual in post-term than term stillbirths (46.5% vs. 19.8%, p value= 0.001) (Stormdal et al., 2014).

The study aimed to identify the cause of stillbirths in low and middle-income settings and compare methods of assessment (Aminu et al., 2019). A prospective, observational study in 12 hospitals in Kenya, Malawi, Sierra Leone, and Zimbabwe. Stillbirths (≥28 weeks‟ gestation) were reviewed to assign the cause of death by

15 healthcare providers, the result shows the stillbirth rate (per 1000 births) was 20.3 in Malawi, 34.7 in Zimbabwe, 38.8 in Kenya, and 118.1 in Sierra Leone.

Half (50.7%) of all stillbirths occurred during the intrapartum period (“Understanding cause of stillbirth: a prospective observational multi-country study from sub-Saharan Africa,” 2019). The most observed cause of death ranges as per method of assessment and included: asphyxia (18.5%–37.4%), placental disorders (8.4%–15.1%), maternal hypertensive disorders (5.1%–13.6%), infections (4.3%– 9.0%), cord difficulties (3.3%–6.5%), and ruptured uterus from obstructed labour (2.6%–6.1%). The cause of stillbirth was not known in 17.9%–26.0% of cases (Aminu et al., 2019).

The studies that were done in low- and middle-income countries revealed that obstetric problems during the intrapartum period, fetal mal-presentation, preterm delivery, prolonged labor, or cesarean section, and preeclampsia are associated with intrapartum stillbirth (Nahar, Rahman, & Nasreen, 2013 & Jammeh, Vangen, & Sundby, 2010).

2.4 Conceptual framework

This is a graphic way of explaining the association between the variables and interested outcome. Acordig to the literature above, the variables listed in the frame work can cause the outcome of interest either directly, indirectly or combination of both variable. Means that social demographic example age which explained that young age below 20 years or older age above 35 years are risk factor for adverse fetal outcome. Therefore the predictors of stillbirth can be one factor or more than one factors as stated by the Triple risk model explain that fetal loss, especially the late stillbirth (Gestational age ≥28 weeks) is a combination of more than one characteristic, maternal and fetal characteristic.

CONCEPTUAL FRAMEWORK

Independent Variables Dependent Variables

Social demographic variable -Maternal Age

-Marital status -Maternal Education level -Residence

-Occupation -Smoking habit -Alcohol habit

Maternal Factors -Parity -Birth interval -Gestational age - Antenatal attendance Stillbirth -Use of local potion in index preg -Maternal infections -Maternal medical conditions - Previous stillbirth Live born Fetal factors - Fetal presentation - Fetal birth weight -Cord around the neck - IUGR

Obstetric Factors

- Antepartum haemorrhage - Placenta praevia (APH) - Admission status - Cord accident - PPROM and PROM

Figure 2: Conceptual Framework

CHAPTER THREE 3.0 RESEARCH METHODOLOGY

3.1 Study Area

The study was conducted in Pwani Region of Tanzania; it was a hospital-based study. Pwani is one of the 26 regions in Tanzania Mainland. The Region is bordered by the Tanga Region in the North, to the East by Dar es Salaam Region and the Indian Ocean, to the South by the Lindi Region, and to the West by the Morogoro Region. The Region covers a total area of 32,407 square Kilometers. The total population in the region is 1,265,504, male 621028 and female 644,476 source-NBS (2015/16) sub National population projection. The region has 9 administrative councils which are Bagamoyo District Council, Kibaha District Council, Kibaha Town Council, Kisarawe District Council, Chalinze District Council, Mafia District Council, Mkuranga District Council, Rufiji District Council, and Kibiti District Council (National Bureau of Statistics, Population and Housing Census, 2012, Dar- es-Salaam, Tanzania available from www.tzdpg.or.tz).

The main societies of Pwani are Zaramo and Ndengereko, though the Region is comprised of other societies. Their cultural drink includes a local brew known as Mnazi which is mostly consumed for recreation and virtual purposes during social local markets known as Minada as well during cultural dances known as “Mdundiko” and „Kigodoro. There are also some cultural beliefs, especially, associated with sicknesses in that majority believe in which craft when someone falls sick. Pwani Region also has some health facilities that serve the community.

The region has a total of 337 health facilities among those Hospitals are 9 were by 7 public and 1 faith-based organization and 1 private. Health centers are 29, public 16, faith-based organization 6, and 7 are private. Dispensaries are 292 whereby 230 publics, 22 faith-based organizations, 32 private, and 9 militaries. Almost all facilities are providing ANC services and deliveries being conducted mostly in hospitals and Health centers, very few uncomplicated deliveries are conducted in dispensaries, while most cases being referred to Health Centre and Hospital for delivery. Care provided during ANC visits are like physical examination of pregnant women, Health education about danger signs of pregnancy, testing and counseling

18 for HIV/AIDS, Vaccination of Tetanus toxoid, micronutrients provision and checking for Hemoglobin level, etc.

Pwani Region is selected purposively, due to its slow reduction of number of stillbirths as stated in local data DHIS as “is about 513, 475 and 545 stillbirths occurred in 2017, 2018 and 2019 respectively”. In addition, there is no data published in Pwani Region, concerning predictors of stillbirths. Furthermore, the culture, and taboos of people in Pwani believe much in witchcraft which can predispose pregnant women to use of local herbs. Hospitals and Health centers from both public and faith-based hospitals, were involved due to the following criteria: having both Basic Emergency Obstetric and Neonatal Care (BEMONC) and Comprehensive Emergency Obstetric and Neonatal Care (CEMONC) services, a large number of deliveries and if facilities were able to manage any complication which risen during labour monitoring.

In Tanzania, is the only prospective study done, another study done in northern Tanzania was a retrospective cohot study.

3.2. Study Design

This study was a hospital based matched case-control with quantitative approaches and ratio 1:2, one post-delivery mother with stillbirth was matched with two post- delivery mothers with live borns This design was good to help to determine multiple exposures to stillbirths. Post delivery-mothers were matched based on their ages and time of delivery as follows: Post delivery-mother, who face stillbirth with age below 20 years, 20-35years or above 35, was included as case and thereafter two post- delivery mothers with live borns were chosen with the same age category. The duration was from May to August 2020.

Figure 3: Pwani Region Map Showing District Councils

3.3 Study Population

The population of this study was all the post-delivery mothers who gave birth to stillbirths in labour wards within 24 hours during the study and all post-delivery mothers who gave birth to live borns were consulted to participate in the study regardless of parity and mode of delivery. The cases were chosen which all post- delivery mothers who give birth to stillbirth were and control were selected from the same hospital/health facility but with live birth, delivered next to cases with the ratio 1:2 respectively. Participants were matched based on maternal age which was categorized as 15-19years as below 20 years, 20-35 years as recommended age for reproductive with good experience and better outcomes, and lastly age 36-49 years as at risk reproductive age. The duration was from May to the end of August 2020.

3.3.1 Definition of Case and Control

Cases were all post delivery mothers gave birth to stillbirths in labour room within 24 hours Hospital stay in Pwani Region, between may 2020 to Augost 2020.

Controls were all post-delivery mothers gave birth to live borns within the same period as to stillbirth in labour room, within 24 hours Hospital stay in Pwani Region, between May 2020 to Augost 2020.

3.3.2 Inclusion Criteria for cases

All post-delivery mothers who give birth to stillbirths (gestational age ≥28) at health facilities during the study period.

3.3.3 Exclusion Criteria cases

Post-delivery mothers who gave birth to stillbirth (gestational age ≥28) at health facilities in Pwani region during the study period with mental illness. All post-delivery mothers who gave birth to stillbirth (gestational age ≥28) at health facilities in Pwani region during the study period that was seriously sick.

3.3.4 Inclusion Criteria for controls

All post-delivery mothers who gave birth to live births (Apgar score ≥7) at health facilities in Pwani region during the study period

3.3.5 Exclusion Criteria for controls

All post-delivery mothers who gave birth to live births (Apgar score ≥7) at health facilities in Pwani region during the study period with mental illness. All post-delivery mothers who gave birth to live birth (Apgar score ≥7) at health facilities in Pwani region during the study period that was seriously sick.

3.4 Sample Size and Sampling

3.4.1 Sample Size

The size was obtained through Shein-Chung Chow, Hansheng Wang, and 2007‟s formula.

Where:

n= Case group Sample size. r=Ratio of controls to cases

p*=A measure of variability (Pooled Proportion = (P1 + P2) ̸2)

Zβ=Represent the desired power typically (0.84 at 80%)

Zα/2=Represent the desired level of statistical significance typically (1.96).

P1=proportional of cases 14.12% -from a previous study in India, (Ananthan, Nanavati, Sathe, & Balasubramanian, 2018) . P2=proportional of controls 2.35% -from a previous study in India, (Ananthan et al., 2018)

r=1:2

2 Therefore n= r+1 (p1+p2/2) (1-p1+p2/2) (zβ+zα/2) 2 r (p1-p2)

Therefore n= (1+2) 0.08235(1-0.08235) (1.96/2+0.84)2 2 (14.12-2.35)2

n = 1.5 x 0.08235 x 0.91765 x 7.84 =64.1 0.01385329

Sample size in the case group were 65 to get the value of control the ratio of 1:2, was used there-fore cases were 65 and controls 130, the total sample size was 195. 3.4.2 Sampling Technique

Purposive sampling was employed in selecting region referral hospitals and all district hospitals, as they provide delivery services and have large number of deliveries.

Stratified sampling was used to select urban and rural Health centers by which 10 Health Centers were selected randomly by the means of the lottery replacement

22 method, thus 5 Healthy centers from urban and 5 Health centers from rural were included in the study.

Cases were all post-delivery mothers who faced stillbirths in labour room taken from health facilities by which controls were two post-delivery mothers give birth to live born consecutively next to stillbirth and was matched by age, to women with stillbirth in labour room, within 24 hours of hospital stay.

Health facilities included in a study:

Tumbi Designed Regional Referral Hospital,

District hospitals: Kisarawe District Hospital, Bagamoyo District Hospital, Mafia District Hospital. Mkuranga District Hospital, Rufiji District Hospital, Kibiti Hospital, Msoga District Hospital, Mchukwi Hospital,

Health centres (Urban): Mkoani Health Centre, Kongowe Health Centre, Chalinze Health Centre, Medwel Health Centre, Kibiti Health Centre

Health centres (Rural): Mlandizi Health Centre, Masaki Health Centre, Kilongwe Health Centre, Kerege Health Centre, and Kilimahewa Health Centre.

3.5 Data Collection Methods

Nine research assistants with different level of qualification that include 8 registered nurses and 1 medical doctor, were trained for two days before data collection.

For controls: Interviewer administered questionnaire with post-delivery mother in labour room was carried out to determine the predictors of stillbirths, during their hospital stay.

For cases: All mothers, who deliver to stillbirths, after have been consented to participate to study were asked to suggest time and place, when their comfortable for the interview, thereafter they were interviewed when there comfortable with time are place chosen. Most of them were chosen to be interviewed the next day, (n=58), and other (n=7) were interviewed on the first postpartum visit. Patography and ANC were reviewed to collect other information, including fetal outcome, Apgar scoring at one minute and five minutes and intrapartum deaths. Since data collection was done during COVID-19 precaution against protection was ensured all researcher

23 assistants, principal investigator and the study participants used sanitizer and masks, as well as one metre between the study participants was observed.

3.6 Data Collection Tools – Instruments

A Structured questionnaire and documentary review were used for data collection. The standardized questionnaire was adopted and modified a study from Ghana of (Badimsuguru et al. 2016) (Appendex 4, Dodoso-swahili).

3.7 Validity

Validity means instrument measures what it supposed to measure. The questionnaire was shared with research supervisor, peer group review and also inspected by a midwife expert, obstetrician, and statistician experts to make sure for content validity of the tool. The experts were asked to pass through each question to see if it is answering the research questions. The expert feedback/corrections were evaluated and compared to determine the degree of validity of content, and the modifications of questions suggested were considered prior to the collection of data.

3.8 Instruments reliability

Tool was pre-tested in Dodoma General Hospitals and marked by Obstetrician and nurse midwives before the actual data collection to test the accuracy and practicability of tools and to ensure the tool information will answer the research questions. Swahili version questionnaire was used (Appendex 4, Dodoso-swahili). Minor corrections were made before conducting the research.

3.9 Definition of variables

3.9.1 Dependent variables

 Stillbirth is a baby born dead (without spontaneous respiration or heartbeat) with 1000 grams‟ birth weight or great or equal to the gestation of 28 weeks.

 Live born is a baby born alive (Apgar score ≥ 7 in one minute and 10 in 5 minutes) with birth weight ≥1000 or gestation age of 28 weeks.

3.9.2 Independent variable

 Social-demographic characteristics (age, education, marital status, gravid, parity, ethnic group, employment status)

 Maternal factors (infection, maternal medical conditions, birth interval gestation age smoking alcohol intake antenatal attendance)  Fetal factors (congenital abnormality, intrauterine growth restriction fetal birth weight fetal trauma  Obstetric factors (anterpurtum haemorrhage cord accident true knot (cord), PPROM and PROM, placenta abruption placenta praevia

3.10 Measurements of Variables

Dependent variables

Stillbirth measurement relied on the physician diagnosis written on patient case note and its gestional age observed on ANC card/patography.

Live born measurement relied on the physician/nurse midwife documentation on patography noting the Apgar scoring.

Independent Variables

Social demographic characteristics were measured by 12 items in the questionnaire and a nominal scale was used for marital status, educational level and occupation while continuous scale were measured the parity, age.

Maternal Factors: Were measured by 31 items using categorical and interval scales.

Fetal Factors: Were measured by 17 items using categorical scales and numerical.

Obstetric Factors: Were measured by 8 items using a numerical scale.

3.11 Data Analysis

Each questionnaire was checked for completeness and accuracy before the participant left the venue/ discharged from hospital and all completed questionnaire was given the code number, data were analyzed by using statistical package for social science (SPSS) Version 20, the process was involved descriptive statistics to describe the population sample and relevant proportions, in cross-tabulations and frequency table between independent and outcome; and chi-square test for the presentation of relationship between research variables during statistical analysis, numerical variables was represented by categorical data by complete numbers and percentages, odds ratios was determined to evaluate the association between stillbirth

25 and predictors of stillbirths ( maternal factors, fetal factors and obstetric factors), p- value of ˂0.05 was stated statistically significant, binary and multinomial logistic regression was used to determine the association of independent variable and stillbirth, all the process of analyzing data was cemented by the stated objectives of the study.

3.12 Ethical consideration

The ethical issue, was highly observed so as to ensure human rights, psychological issues of participants, and country policies were adhered by the researcher. Ethical clearance was obtained from the University of Dodoma, after being approved by the research committee of the University of Dodoma (Appendex 6, Ethical clearance form).

A letter requesting permission to conduct the study was sent to the Regional Administrative Secretary (RAS) (Appendex 7, Permission letter to conduct research in Pwani Region), and regional medical officer (RMO) thereafter to directors of the selected hospitals/Health centers and heads of Departments of Obstetrics and Gynecology. The verbal consent was obtained from post-delivery mothers after an explanation of the purpose of the study and requested to sign the informed consent form (Appendex 2, consent form-swahili version). Participation was completely free and respondents who agreed to participate in the study were voluntarily and were free to withdraw from the study at any time. No name of the respondents was included in the questionnaires. All information was held confidential and kept safe under lock.

Since Stillbirth is a very sensitive topic and there is the potential of arousing negative emotions when interviewing these women, shortly after experiencing stillbirth, the following considerations were taken to minimize harm to respondents.

Potential post-delivery mothers were approached before they leave the hospital and brief information was given as well as an invitation to receive further details. The contact method for further communication was be chosen by potential post-delivery mothers who accept the invitation for further details and may include phone calls or posts. This initial contact was made by a midwife or nurse who is already known to the bereaved mothers as they have already established relationships and trust when caring for the patients.

Data collection interviews were conducted in a private environment without any interruption. Bereaved women who agree to participate were given the opportunity to choose the setting where data collection was taken place.

If a post-delivery mothers with stillbirth becomes distressed during the interview, a decision to interrupt the interview was guided by the post-elivery mothers and interviewer's understanding. Psychotherapy and counseling were provided to post- delivery mothers, ensuring minimal harm from the interview process.

Respondent anonymity was ensured by not including any identity information in collected data.

CHAPTER FOUR

4.0 RESULTS AND DISCUSSION

4.1 RESULTS

4.1.1 Social Demographic Characteristics of the Study Participants

A total of 195 (65 cases and 130 controls) participated in the study, in both group, the majority were aged between 20-35 years, 43 (66.2%) for cases and85 (65.4%) for controls. The majority of the participants were overweight of which the controls predominated 80 (61.5%). With respect to residence, the proportion of women from urban area among the control 87 (66.9%) and cases 35 (53.8%). The percentage of married women were minority in cases 54 (83.1%), in control group was 106 (81.5%). In this study, majority were employed with a higher proportion among the cases 54 (83.1%) and controls were 97 (74.6%). Majority of the respondents never smoked cigarettes in both groups. Similarly, minority consumed alcohol (3.1%) in both groups. In both group the majority of participants were attended in district hospitals, for cases 35 (53.8%) and controls 70 (53.8%). Table 1.

Table 1: Frequency distributions of Social demographic characteristic of study participants (N=195) Variable Cases Control Total n= 65 n= 130 (n=195) n % n % n (%) Level of the facility Regional Hospital 19 29.2 33 25.4 52 29.2 District Hospital 35 53.8 70 53.8 105 53.8 Health Centre 11 16.9 22 16.9 33 16.9 Age of the mother (yrs) 15-19 8 12.3 16 12.3 24 12.3 20-35 43 66.2 85 65.4 128 65.6 36-49 14 21.5 29 22.3 43 22.1 BMI Normal 11 16.9 31 23.8 42 21.5 Overweight 39 60.0 80 61.5 119 61.0 Obese 15 23.1 19 14.6 34 17.4 Residence Urban 35 53.8 87 66.9 122 62.6 Rural 30 46.2 43 33.1 73 37.4 Education level No education 5 7.7 5 3.8 10 5.1 Primary 38 58.5 82 63.1 120 61.5 Secondary 19 29.2 32 24.6 51 26.2 Tertiary 3 4.6 11 8.5 14 7.2 Marital status Married 54 83.1 106 81.5 160 82.1 Single 11 16.9 24 18.5 35 17.9 Occupation Employed 54 83.1 97 74.6 151 77.4 Unemployed 11 16.9 33 25.4 44 22.6 Alcohol intake Yes 2 3.1 4 3.1 6 3.1 No 63 96.9 126 96.9 189 96.9 Smoking Yes 1 1.5 1 0.8 2 1.0 No 64 98.5 129 99.2 193 99.0

4.1.2 Maternal Clinical Characteristics of the Study Participants with Relationship to Stillbirth The majority of participants took Folic acid during pregnancy for controls 129 (99.2%) and for the cases 59 (90.8%). Laboratory investigations was also checked from the ANC card and the result showed that, minority were VDRL positive both in control 1 (0.8%) and cases 1 (1.5%). Similarly, minority were seroconverted for cases 2 (3.1%) and for the controls 8 (2.2%). The Blood group of the mothers was

29 also checked and the majority of participants were group O+, for controls 68 (52.4%) and for cases 30 (46.2%). During the antenatal period of the index pregnancy, the majority of the pregnant women in this study took 3-4 doses of Sulfadoxine pyrimethamine, for controls 117 (90.0%) and for cases 28 (43. 1%). In regards to local herb use, minority gave a history of using local herbs with a higher proportion among the cases 21 (32.3%) and for controls 10 (7.7%). In both group, the majority of participants attend antenatal clinic less than 4 visits, for cases 43 (66.2%) and for controls 48 (36.2%). Booking to Antenatal cinic majority book late for contrls 80 (61.5%) and for cases 40 (61.5%). Regarding Hemoglobin at admissionto labour ward, anaemic mother were dominant with high proportion among cases 46 (70.8%) compared to control 44 (33.8%), diagnosed with malaria in pregnant, manority were positive, for cases 13 (40%) and for control 6 (4.6%). As presented in Table 2

Table 2: Frequency distribution of maternal factors contributing to stillbirth (N=195) Variable Cases Control Total n= 65 n= 130 (n=195) n % n % n (%) GA at 1st booking WHO recommended 11 16.9 24 18.5 35 17.9 Early booking 14 21.5 26 20.0 40 20.5 Late booking 40 61.5 80 61.5 120 61.5 Parity Primipara 9 13.8 27 20.8 36 18.5 Multipara 44 67.7 96 73.8 140 71.8 Grand multipara 12 18.5 7 5.4 19 9.7 Birth Interval <24 months 20 30.7 9 6.9 29 14.9 ≥ 24 months 35 53.8 95 73.1 130 66.7 None 10 15.4 26 20.0 36 18.4 GA at complete weeks Preterm 19 29.2 13 10.0 32 16.4 Full term 46 70.8 117 90.0 163 83.6 Number of ANC visit Less visit 43 66.2 48 36.9 91 46.6 Adequate visit 22 33.8 83 63.1 105 53.4 Folic acid taken during pregnancy Yes 59 90.8 129 99.2 188 96.4 No 6 9.2 1 0.8 7 3.6 History of Using Local Herbs Yes 21 32.3 10 7.7 31 15.9 No 44 67.7 120 92.3 164 84.1 VDRL status Reactive 1 1.5 1 0.8 2 1.0 None Reactive 64 98.5 129 99.2 193 99.0 HIV status Positive 2 3.1 8 6.2 10 5.1 Negative 63 96.9 122 93.8 185 94.9 Diagnosis of HIV Before pregnancy 2 3.1 6 4.6 8 4.1 During pregnancy 0 0.0 2 1.5 2 1.0 None 63 96.9 122 93.9 185 94.9 Anti-retroviral Drugs use Yes 2 3.1 8 6.2 10 5.1 No 63 96.9 122 93.8 185 94.9 Maternal blood group A+ 19 29.2 35 26.9 54 27.7 B+ 10 15.4 15 11.5 25 12.8 AB+ 6 9.2 12 9.2 18 9.2 O+ 30 46.2 68 52.3 98 50.3 HB at admission to labour Anaemic 46 70.8 44 33.8 90 46.2 Not anaemic 19 29.2 86 66.2 105 53.8

Malaria in index pregnancy Yes 13 20.0 6 4.6 19 9.7 No 52 80.0 124 95.4 176 90.3 Sulfadoxine pyrimethamine given <2 doses 37 56.9 13 10.0 50 25.6 3-4 doses 28 43.1 117 90.0 145 74.4 Admission in early pregnancy Yes 27 41.5 9 6.9 36 18.5 No 38 58.5 121 93.1 159 81.5

4.1.3 Fetal Clinical Characteristics Contributing to Stillbirth

Fetal clinical characteristic was also assessed and the majority of the fetuses presented in cephalic for the control 125 (96.2%) and in cases 48 (73.8%), the majority of the post-delivery mother had singleton pregnancies, in the control 126 (96.9%) and cases 62 (95.4%). The manority of fetuses born with cord around the neck, in cases was 17 (73%) and control only 3 (2.3%). Majority of the post-delivery mothers give birth to baby weigh between 2.5kg-4kg, in cases were 43 (66.2%) and controls 119 (91.5%). The majority of the babies assisted to breathe were ended up dead with high proportion among cases 20 (30.8%) and controls 6 (4.6%). Table 3

Table 3: Frequency distribution of Fetal factors contributing to stillbirth

Variable Cases Control Total n= 65 n= 130 (n=195) n % n % n (%) Fetal Presentation Cephalic 48 73.8 125 96.2 173 88.7 Breech 17 26.2 5 3.8 22 11.3 Birth Weight <2.5 kg 20 30.8 8 6.2 28 14.4 2.5-4.0 kg 43 66.2 119 91.5 162 83.1 >4.1 kg 2 3.1 3 2.3 5 2.6 Number of fetuses Singleton 62 95.4 126 96.9 188 96.4 Multiple 3 4.6 4 3.1 7 3.6 Baby Assisted to breathe Yes 20 30.8 6 4.6 26 13.3 No 45 69.2 124 95.4 169 86.7 Cord around the neck Yes 17 73.0 3 2.3 18 9.2 No 48 27.0 127 97.7 177 90.8

4.1.4 Frequency Distribution of Obstetric Factors Contributing to Stillbirths

Regarding Obstetrical factors, the proportion of the referral from other facility was high for cases (67.7%) as compared to the control (8.5%). In case of membrane rupture before labour is increased in cases (38.5%) compared to control (0.8%). In both groups (cases and control) mode of delivery SVD and C/S are almost with the same proportion (83.1%, 88.5%) and (16.9%, 11.5%) respectively. Results have shown that, a higher proportion who had Severe per-vaginal bleeding 15 (23.1%) were cases group as compared to control. The majority 12 (18.5%) who had Cord prolapse were from the group of cases. Concerning period of rupture of membrane, majority 25 (38.5%) of the cases the rupture was before labour started with the majority having foul smelling liquor.Table 4

Table 4: Frequency Distribution of Obstetric Factors on Stillbirth Variable Cases Control Total n= 65 n= 130 (n=195) n % n % n (%) Severe per-vaginal bleeding Yes 15 23.1 1 0.8 16 8.2 No 50 76.9 129 92.2 179 91.8 Cord prolapse Yes 10 15.4 4 3.1 14 7.2 No 55 84.6 126 96.9 181 92.8 Mode of Delivery SVD 54 83.1 115 88.5 169 86.7 C/S 11 16.9 15 11.5 26 13.3 Admission status Referral from other 44 67.7 11 8.5 55 28.2 facility Admission from 21 32.3 119 91.5 140 71.8 home Membrane rupture Before labour started 25 38.5 1 0.8 26 13.3 During labour 40 61.5 129 99.2 169 86.7 Hours since rupture < 24 hours 42 64.6 128 98.5 170 87.2 ≥24 hour 23 35.4 2 1.5 25 12.8 Foul smelling liquor Yes 22 33.8 1 0.8 23 11.7 No 43 66.3 129 99.2 172 88.2

4.1.5 Relationship between Social Demographic characteristics and Stillbirths among post-delivery mothers in Pwani Region The result of study shows that maternal age (in years) of the study participants was not significantly associated with still birth (p-value=0.940) Other variables like Residence, Education Level, Employment status and Body Mass Index, was not significantly associated with still birth (p-value=>0.05). Table 5

Table 5 Relationship between Social Demographic characteristic and stillbirths among post-delivery mothers in Pwani Region (N=195)

Variable Cases(n=65) Controls X2 P- (n=130) value n (%) n (%) Age (yrs) 15-19 8 30.8 18 69.2 20-35 43 34.1 83 65.9 0.124a 0.940 36-49 14 32.6 29 67.4 BMI Normal 11 26.2 31 73.8 Overweight 39 32.8 80 67.2 2.761a 0.252 Obese 15 44.1 19 55.9 Residence Urban 35 28.7 87 71.3 Rural 30 41.1 43 58.9 3.164a 0.075 Marital status Married 54 33.8 106 66.2 Single 11 31.4 24 68.6 0.070a 0.792 Education Level Not gone to 5 50.0 5 50.0 school Primary 39 32.5 81 67.7 Secondary 18 35.3 33 64.7 2.269a 0.519 Tertiary 3 21.4 11 78.6 Employment

Self employed 54 35.8 97 64.2 Public and other 11 25.0 33 75.0 1.776a 0.183 employments Alcohol intake Yes 2 33.3 4 66.7 No 63 33.3 126 66.7 0.000a 1.000 Smoking Yes 1 50.0 1 50.0 No 64 33.1 129 66.8 0.253a 0.615

4.1.6 Relationship between Maternal Factors and Stillbirths among post- delivery Mothers in Pwani Region

In this study, the post-delivery mothers, who had premature gestation age in weeks was significantly associated with stillbirth (p value=0.001). Among cases the post- delivery mothers who were grand multiparous was significantly associated with stillbirth (p value=0.011). Among cases the majority were born with mother who had inadequate ANC visit 43 (47.8%) compared to controls 47 (52.2%) (p value=0.000). Hemoglobin level ranges at admission to labour was assessed and the result showed that among cases majority was anaemic 46 (51.1%) compared to controls 44 (48.9%) (p value=0.000). Furthermore in cases, majority had taken local herbs, 21(67.7%) compared to controls 10 (32.3%), admission in early pregnant, birth interval shows statisticl significant associated with stillbirth (p value=0.000), malaria in pregnancy also was associated with stillbirth (p value=0.001). Other factor like 1st antenatal booking and medical conditions i.e VDRL and HIV status were not significantly associated with stillbirth (p value= >0.05).Table 6.

Table 6: Relationship between maternal factors and stillbirths among post- delivery mothers in Pwani Region (N=195)

Variable Cases (n=65) Controls X2 P- (n=130) value n (%) n (%) GA at 1st booking WHO recommended 11 31.4 24 68.6 Early booking 14 35.0 26 65.0 Late booking 40 33.3 80 66.7 0.27a 0.987 Number of ANC visit Inadequate visit 43 47.8 47 52.2 Adequate visit 22 21.0 83 79.0 15.693a 0.000 HB at admission to labour Anaemic 46 51.1 44 48.9 Not anaemic 19 18.1 86 81.9 23.771a 0.000 Folic acid taken during pregnancy Yes 59 31.4 129 68.6 No 6 99.2 1 0.8 8.965a 0.000 History of Using Local Herbs Yes 21 67.7 10 32.3 No 44 26.8 120 73.2 19.638a 0.000 VDRL status Reactive 1 50.0 1 50.0 None Reactive 64 33.1 129 66.8 0.253a 0.615 HIV status Positive 2 20.0 8 80.0 Negative 63 34.1 122 65.9 0.843a 0.358 GA at complete weeks Preterm 19 59.4 13 40.6 Full term 46 28.2 117 71.8 11.683a 0.001 Parity Primipara 9 25.0 27 75.0 Multipara 44 31.4 96 68.6 8.959a 0.011 Grand multipara 12 63.2 7 36.8 Admission in early pregnancy Yes 27 70.5 9 25.0 No 38 23.9 121 76.1 34.493a 0.000 Malaria in index pregnancy Yes 13 68.4 6 31.6 No 52 29.5 124 70.5 11.663a 0.001

Sulfadoxine pyrimethamine given <2 doses 35 53.8 10 7.7 3-4 doses 28 43.1 117 90.0 52.931a 0.000

Not received 2 3.1 3 2.3 Birth Interval <24 months 20 69.0 9 31.0 ≥ 24 months 35 26.9 95 73.1 19.473a 0.000 None 10 27.8 26 72.2 Maternal blood group A+ 19 29.2 35 26.9 B+ 10 15.4 15 11.5 AB+ 6 9.2 12 9.2 0.910a 0.823 O+ 30 46.2 68 52.3

4.1.7 Relationship between Fetal Factors and Stillbirths among Post-Delivery Mothers in Pwani Region

When the association between Fetal factors and stillbirths among post-delivery mothers was assessed, the result showed that, Fetal Presentation was significant associated with stillbirth (p value=0.000). Assisted to breath among asphyxiated babies, if not done was significantly association with stillbirth (p value=0.000). Birth weight below 2.5kg, showed associated with stillbirth (p value=0.000). Number of fetuses was not significant associated with stillbirths (p value=0.586). Cord around the neck was significant associated with stillbirth (p value=0.000). Table 7

Table 7: Relationship between Fetal factors and stillbirths among post-delivery mothers in Pwani Region (N=195)

Variable Cases (n=65) Controls X2 P- (n=130) value n (%) n (%) Fetal Presentation Cephalic 48 27.7 125 72.3 Breech 17 77.3 5 22.7 21.544a 0.000 Birth Weight <2.5 kg 19 67.9 9 32.1 2.5-4.0 kg 45 27.8 117 72.2 20.430a 0.000 >4.1 kg 1 20.0 4 80.0 Number of fetuses Singleton 62 33.0 126 67.0 Multiple 3 42.9 4 57.1 0.296a 0.586 Cord around the neck Yes 17 85.0 3 15.0 No 48 27.4 127 72.6 26.771a 0.000 Assisted to breath Yes 20 76.9 6 23.1 No 45 26.6 124 73.4 25.651a 0.000

4.1.8 Relationship between Obstetric Factors on Stillbirths among Post-Delivery Mothers in Pwani Region

Regarding Obstetrical factors, the current study showed that rupture of membranes, duration of time since ruptured, and smell of liquor were significantly associated with stillbirth (p value=0.000) respectively, this was similar to per-vaginal bleeding (APH) before labour and Cord prolapse (p value=0.000). Admission status was significantly associated with stillbirth (p value=0.000). Other variables like mode of delivery did not show significance with stillbirth (p value=0.297). Table 8

Table 8: Relationship between obstetric factors on stillbirths among post- Delivery mothers in Pwani Region (N=195)

Variable Cases (n=65) Controls X2 P- (n=130) value n (%) n (%) APH Yes 15 99.8 1 0.8 No 50 27.8 129 72.2 35.500a 0.000 Cord prolapse Yes 10 71.4 4 28.6 No 55 30.4 126 69.6 9.850a 0.002 Mode of Delivery SVD 54 32.0 115 68.0 C/S 11 42.3 15 57.7 1.087a 0.297 Admission status Referral from other 44 80.0 11 20.0 facility Admission from home 21 15.0 119 85.0 75.075a 0.000 Rupture of membrane Before Labour Started 24 92.3 2 7.7 During Labour 41 24.3 128 75.7 46.953a 0.000 Hours since rupture < 24 hours 42 24.7 128 75.3 ≥24 hour 23 92.0 2 8.0 44.414a 0.000 Foul Smelling liquor Yes 22 99.2 1 0.8 No 43 25.3 129 74.7 49.595a 0.000

4.1.9 Logistic Regression on the Maternal Predictors of Stillbirths among Post- Delivery Mothers at Pwani Region

Logistic regression analysis showed that, mothers who had inadequate ANC visits were three times more likely of having stillbirth compared to their counterparts who

38 had adequate ANC visits (AOR=3.289, 95% CI 1.683-6.427, p value=0.000). Mothers who were anaemic were four times more likely to have stillbirth compared to those who were not anaemic (AOR=4.690, 95% CI 2.384-9.225, p value=0.000). As history admission in early pregnancy shows a strong association with stillbirth (AOR=9.828, 95% CI 2.079, 16.146, p value=0.000).Other factors which show the association with stillbirth were parity, gestational age at delivery, not received dose of sulfadoxine pyrimethamine, malaria in pregnancy, anaemic state during admission to labour ward, folic acid intake (AOR=5.693, 95%, CI 1.971-16.446, p value=0.009; AOR=4.024,95% CI 1.704 -9.506, p value=0.001; AOR=5.171, 95% CI 2.104- 12.712, p value=0.000; AOR=3.328, 95% CI 0.513-21.598, p value=0.208; AOR=5.793, 95% CI 2.079-16.146, p value=0.001).

Fetal characteristics which show association with stillbirth were fetal presentation other than cephalic (AOR=12.591, 95% CI 3.966-39.973, pvalue=0.000) Cord around the neck (AOR=15.326, 95% CI 4.271-54.990, p value 0.000), and birth weight less than 2.5kg (AOR=11.405, 95% CI 4.271-35.243). Obstetric characteristics which shows the association with stillbirths were mother who were referred from other facility were seventeen times more likely to have stillbirth compared to those who were admitted from home (AOR=17.716, 95% CI 7.867- 39.897, p value=0.000).History of cord prolapse is thirteen more likely to be associated with stillbirths (AOR=13.656, 95% CI 2.840-6.5655, p value=0.001). Mothers with a history of early rupture of membrane i.e rupture of membrane before the onset of labour as twenty nine more likely to be associated with stillbirth compared with rupture of the membrane during labour (AOR=29.819, 95% CI 6.464- 13.564, p value=0.000).Table 8 below

Table 9: Logistic Regression on the Maternal predictors, the Fetal Predictors, and Obstetric Predictors of stillbirths among post-delivery mothers at Pwani Region (N=195)

Variable OR 95% CI P-value AOR 95% CI P- OR AOR value Lower Upper Lower Upper ANC visit Adequate Ref. visit Inadequate 3.452 1.846 6.455 0.000 3.289 1.683 6.427 0.000 visit Folic Acid Intake

Yes Ref. No 13.119 1.545 11.142 0.018 11.456 1.333 98.464 0.026 HB at admission to labour Not Ref. Anaemic Anaemic 4.372 2.480 9.031 0.000 4.690 2.384 9.225 0.000 History of admission in early pregnancy No Ref. Yes 9.553 4.133 22.079 0.000 9.828 4.055 23.820 0.000 Malaria in index pregnancy No Ref. Yes 5.167 1.863 14.330 0.002 5.793 2.079 16.146 0.001 Gestation Age Full term Ref. Preterm 3.717 1.698 8.139 0.001 4.024 1.704 9.506 0.001 Local Herbs No Ref. Yes 5.727 2.501 13.115 0.000 4.738 1.998 11.235 0.000 Parity Primipara Ref. Multipara 5.143 1.550 17.061 0.007 5.399 1.529 19.057 0.009 Grand 3.740 1.379 10.148 0.010 5.693 1.971 16.446 0.001 Multipara Birth Interval None Ref. > 24 5.778 1.976 16.891 0.001 4.998 1.667 14.981 0.004 months <24 6.032 2.509 14.498 0.000 5.171 2.104 12.712 0.000 months Sulfadoxine Pyrimethamine Intake 3-4 doses Ref. <2 doses 0.091 0.028 1.302 0.091 0.209 0.030 1.464 0.115 Not 2.786 0.444 17.472 0.274 3.328 0.513 21.598 0.208 received Fetal Presentation Cephalic Ref. Breech 12.064 3.881 37.496 0.000 12.591 3.966 39.972 0.000 Birth Weight 2.5-4.0 kg Ref. >4.1 kg 5.489 2.312 13.028 0.000 5.528 2.281 13.396 0.000 <2.5 kg 8.444 0.821 26.828 0.073 11.405 0.962 35.243 0.054 Cord Around the Neck No Ref. Yes 14.993 4.204 53.469 0.000 15.326 4.271 54.990 0.000 Assisted to breathe Yes Ref. No 9.185 3.468 24.327 0.000 9.533 3.563 25.506 0.000 APH No Ref. Yes 0.028 0.004 0.220 0.001 0.032 0.004 0.261 0.001 Admission status Admission Ref. from home

Referral 19.220 8.764 42.148 0.000 17.716 7.867 39.897 0.000 from other facility Membrane rupture During Ref. labour Before 37.463 8.488 16.359 0.000 29.819 6.464 13.564 0.000 labour onset Hours since rupture < 24 hours Ref. >24 hour 21.659 6.175 75.966 0.000 19.299 5.222 71.325 0.000 Cord prolapse No Ref. Yes 11.636 2.468 54.864 0.002 13.656 2.840 65.655 0.001

4.2 DISCUSSION

Tanzania is among the African countries with a high prevalence of stillbirths, of 39/1000 perinatal deaths. This is the first Case-control study carried out at Pwani Region on predictors of stillbirth among post-delivery mothers. This study gives data on predictors of stillbirth where at the area there is no any data published, so the study intended to compare and confirm if the known predictors are the same to the area of study. The results show the maternal factors, fetal factors, and obstetric factors were significantly associated with stillbirth after adjusting for potential confounders. In addition, the other predictor which was found strongly associated with stillbirth was maternal taking local portion during pregnancy. As it is the culture of people in Pwani region believes in witchcraft. This study presents stillbirth rates and risk factors in a rural-urban setting in Pwani Region, which may represent the true picture of any resource constrained country such as Tanzania.

4.2.1 The Influence of Maternal Factors on Stillbirths among Post-Delivery Mothers in Pwani Region Regarding gestation age, those mothers who were preterm were four times more at risk of having stillbirth compared to those who were full term. This was in line with the findings from Australia which showed that, pregnancies of lower gestation age of up to thirty four weeks of gestation are associated with three times greater risk of stillbirth (Malacova et al., 2018). The similarity is due to the fact that, fetal maturity is determined by higher gestation age and less risk for stillbirth (Plotkin et al., 2018).

Concerning local herbs intake, mothers who had a history of taking local herbs during pregnancy were four times more likely of having stillbirth compared to their counterparts who did not consume local herbs, this was in line with a study from Northern Ghana which showed that, a greater proportion of women who had used herbal medicine succumb to miscarriage or stillbirth and still they were using herbal medicines during their current pregnancy (Zakaria & Abubakar 2018). This corroborated with a study done on the prevalence of herbal medicine use and associated factors among pregnant women attending antenatal clinic at Mbeya Referral Hospital in 2010 which showed that, local herbs use was significantly associated with; Fetal distress, stillbirth and excessive uterine contraction, and these were the most common possible complications of herbal medicine (Mbwanji, 2010).

The similarity in the findings of the study is due to the fact that, local herbs may result in uterine hyperstimulation which may lead to fetal hypoxia and premature delivery as hence perinatal mortality (Mbwanji, 2010).

Parity was assessed and grand multiparous were five times more at risk of having stillbirth compared to the primiparous. This corroborated with the findings from a study at a tertiary hospital in the Northern part of Tanzania which showed that, grand multiparity is associated with maternal and perinatal complications such as, stillbirth and preterm birth(Muniro et al., 2019).

The Antenatal visit was a risk factor for stillbirth since mothers who had less ANC visits were three times at risk of having stillbirth compared to their counterparts who had adequate ANC visit this was in line with a study from South Africa which showed that, in low- and-middle-income countries perinatal mortality is significantly higher in the reduced antenatal care visit groups (Lavin & Pattinson 2018). This was supported by a study from Tigray Public Health institutions in Ethiopia which showed that, Incidence of stillbirth among women with incomplete adherence is fourfold when compared to those women with complete adherence to antenatal visits in having a stillbirth (Haftu et al., 2018). This similarity is largely attributed to the fact that, WHO Antenatal Care Trial asserts that increase in a stillbirths is more marked among those mothers with the reduced ANC (Dowswell et al., 2015).

This is consistent with a study done in Nepal India thah found out that reduced ANC visits. Similar to a study done in upper east region Ghana(Minerva Kyei-Nimakoh

2017), poor utilization of ANC also had an increased risk for intrapartum stillbirth(Kc et al., 2016) and a study in Ghana by Badimsuguru (2016) showed that, the odds of stillbirth among three or less ANC clinic visit, were 1.2 times the odds of stillbirth among mothers with a minimum ANC clinic attendance of four times.

However different with this is a study observed by Maaløe et al., (2016) which stated that, intrapartum care, antenatal visits did not appear constant with effective antenatal observation and treatment of both pre- and intra-hospital stillbirths since missed the opportunity for risk identification. Differences may be due to research methodology.

Those mother who had a history of admission in early pregnancy were nine times at risk of having stillbirth compared to those who were not admitted in early pregnancy this was similar to findings of Dudley and colleagues who found that admissions in early pregnancy can predispose the mother to stillbirth if the reason is infections (McClure; Dudley 2010). The similarity is that any conditions like medical or obstetrics conditions which leads to maternal admission is an independent risk factor to unwanted outcome like still birth.

Anaemia in pregnancy is a risk factor for stillbirth since mothers who were anaemic were four times at risk of having stillbirth compared to those who were not anaemic. This was in line with the findings of Nair et al., (2017) who showed that those mothers who had anaemia low haemoglobin concentrations, were five time more at risk of stillbirth compared to those who had normal hemoglobin concentration. The corroboration is due to the fact that given anaemia is most commonly related to iron deficiency, iron supplementation during pregnancy could have an incremental benefit on reducing the risk of stillbirth (Nair et al., 2017).

Those mothers who had malaria in index pregnancy were five times more at risk of having stillbirth compared to those who did not suffer from malaria in the index pregnancy. This was comparable to the findings from a meta-analysis from Australia whereby results showed that, Plasmodium falciparum and Plasmodium vivax malaria in pregnancy detected at delivery increased the odds of stillbirth (Moore et al., 2017). The similarity is due to the fact that malaria infection can cause maternal anemia leading to many complications which can result in stillbirth.

Concerning birth interval, mothers who had previous birth below twenty-four months were five times at risk of having stillbirth compared to those who had not given birth at all. This was similar to findings of a large international cohort of women from fifty-eight LMICs by Swaminathan and colleagues who found that short interpregnancy intervals between the first and second pregnancy were associated with a higher probability of stillbirth (Swaminathan et al., 2020). The similarity is attributed to the fact that shorter interpregnancy intervals, could lead to nutritional depletion, and this reduction can influence maternal body mass index, micronutrient reserves, and can lead to adverse pregnancy and unwanted neonatal outcomes like stillbirth.

Sulfadoxine Pyrimethamine was analysed and the result of the study showed that, the study participants who did not receive doses of Sulfadoxine Pyrimethamine were three times at risk of having stillbirth compared to those who took 3-4 doses of SP, though it was not statistically significant. This was similar to the findings from a study Intermittent Treatment for the Prevention of Malaria during Pregnancy in Benin, whereby the study showed that, higher incidences of spontaneous abortions, stillbirths, and congenital anomalies among pregnant women who did not take SP (Bottero et al.,2009). It corroborated with a study from Sokoto State, Nigeria by Orobaton which showed that, fewer doses of SP taken during pregnancy were associated with higher odds of stillbirth (Orobaton et al., 2016).

It was also in line with the findings from a study by Mace and colleagues who found that women who had more than two doses of IPT had fewer poor birth outcomes like preterm deliveries and stillbirth (Mace et al., 2015). All these similarities are due to the fact that, malaria weakens the immune systems in pregnant women making them inadequately protected from placental malaria and its consequences like stillbirth (Orobaton et al., 2016).

4.2.2 The Influence of the Fetal Factors on Stillbirths among post-delivery mothers in Pwani Region

Fetal Presentation was assessed and the result showed those who presented by breech were twelve times more likely to be born dead compared (stillbirth) compared to those who presented by cephalic. This was comparable to the findings from Kilimanjaro Christian Medical College, in Northern part of Tanzania whereby the

44 authors found that, Non-cephalic presentation is associated with stillbirth (Chuwa et al., 2017). The similarity may be explained by the fact that, difficulty in delivery of a malpresented fetus, leads to prolonged labour, fetal distress, hence death (still birth)( Chuwa et al., 2017).

The current study has shown that, newborns who had Cord around the neck were fifteen times more at risk of stillborn compared to their counterparts who did not have cord around the neck. This was in corroboration to a study by Bhat and colleagues from India, who showed that, cord around the neck accidents comprises about twenty percent of all foetal asphyxia cases, and ten percent of stillbirth were due to umbilical cord complications (Joshi et al., 2017). While in another study, noncoiled umbilical cords are considered as risk factor for poor perinatal outcome and stillbirth (Peesay, 2017).

While Schreiber shown that, the presence of cord around the neck with single loop was not associated with adverse outcomes, but cord around the neck with triple loops was associated with increased risk of intrauterine fetal death and increased rates of Apgar score less than 7 at 1st and 5th minutes (Schreiber et al., 2018). The similarity is due to the, every umbilical cord abnormality places the fetus at risk for stillbirth because cord around the neck causes circulatory compromise which can be termed as strangulation. The pathophysiological mechanisms of strangulation injuries involve venous, arterial obstruction which is arterial spasm due to carotid pressure in the neck and vagal collapse and this can lead to cerebral stagnation, hypoxia, and unconsciousness, hence stillbirth (Peesay, 2012).

Low birth weight continues to be a significant public health problem globally and is associated with a range of both short and long term consequences. The consequences of low birth weight include fetal and neonatal mortality and morbidity, poor cognitive development and an increased risk of chronic diseases later in life (WHO, 2012).The catastrophic effects of LBW in terms of morbidity and mortality for both short and long term consequences, such as an increased rate of caesarean sections, stillbirth, neonatal asphyxia, and mortality, were documented in the literature (Taha et al., 2020).

In this study, babies who had birth weight less than 2.5kg were at eleven times at risk of stillbirth compared to their counterparts who had birth weight between 2.5 kg

45 to 4.0kg. This was similar to study done at Kilimanjaro Christian Medical College, Northern part of Tanzania which showed that, low birth weight of <2500 grams had significant positive associations with stillbirth together with, high birth weight more than 4000 grams were also associated with stillbirth (Chuwa et al., 2017).

In case–control and cohort studies, results demonstrated that low weight is a risk factor for stillbirth, while in other several studies have shown that both the upper and lower extremes of birthweight are associated with an increased risk for stillbirth (Contag et al., 2016).

Jahani and colleagues from India did a study on Factors Affecting Stillbirth Rate in the Hospitals Affiliated to Babol University of Medical Sciences and found that, propounded that stillbirths are more common in weights less than 2500 g (Jahani et al., 2015). Devi and colleagues similarly showed that, stillbirth rates were very high for babies less than 1000gm birth weight (Devi et al., 2018).

The similarity is due to the fact that, infants with low birth weight may have a high risk of death due to their underdeveloped respiratory system. However, those with higher birth weight the increased risk may be explained by difficulty in delivery of a large or malpresented infant, leading to prolonged labor, fetal distress, and death (Avachat, Phalke, & Phalke 2015; Chuwa et al., 2017; Kidanto et al., 2015).The resent study did not find an association between congenital anomaly and stillbirth.

4.2.3 The Influence of Obstetric Factors on Stillbirths among post-delivery mothers in Pwani Region

Being referred from other facility increased the possibility of stillbirth about seventeen times. This was contrary with the findings from Buea and Limbe regional hospitals in Cameroon whereby the authors found that, being referred from another facility increased the risk of stillbirth about four times (Egbe, Ewane, & Tendongfor 2020). The difference could be due to the fact that, mothers may present late in the health facility without knowing whether the fetus had dangers while in the ward therefore first delay might account for risk for stillbirth while the case from Cameroon, most of the health facilities in low income countries have little equipment for intrapartum monitoring and late referral could account for the increased risk for still birth.

On the subject of state of membranes, those mothers who had membranes rupture before the onset of labour were twenty-nine times more at risk of having stillbirth compared to those mothers who had membranes rupture during labour. This was in line with the findings from Sultan Qaboos University Hospital in Oman which showed that, membranes rupture carries a perinatal risk of still birth especially if ruptured before onset of labour. A similarity was also found in a study by (McClure, Dudley, 2010). The similarity between these studies is due to the fact that, the organisms after rupture of membranes may enter the amniotic fluid and ultimately may infect the fetus, later these organisms may damage the vital organs such as the lung or heart hence stillbirth and this is more prevalent if the rupture is more than twenty fours before the onset of labour. (Al-Riyami et al., 2013).

The umbilical cord is a vital intra-amniotic structure that occasionally develops catastrophic complications. In this study, those mothers who had umbilical cord prolapse were thirteen times more at risk of having still birth compared to those who never had still birth. This was comparable to a study Egypt which showed that, the risk of stillbirth in the umbilical cord prolapse occurs due to total acute asphyxia, which occurs when the umbilical cord is compressed between the fetal head and bony pelvis (Sayed Ahmed & Hamdy 2018). The reason for the similarity is attributed to the fact that, umbilical cord prolapse can presents a great danger to the fetus, since during delivery, the fetus can put stress on the cord and this can result in a loss of oxygen to the fetus, and may even result in a stillbirth. In this study antepartum haemorrhage was manority associated with still birth (0.1 times). This was in contrast to the findings from Nepal which showed an association of APH with still birth (Kc et al., 2015). In rural Bangladesh, a study found an association whereby women who had experienced APH had a significantly higher likelihood of their fetus or neonate having an adverse outcome, either perinatal death, stillbirth or early neonatal death compared to those who did not experience APH (Khanam et al., 2017). Although, in the current study those mothers who had APH were very few when compared to those from other studies.

The current study did not found an association between APH and stillbirth, this was contrary to the findings of Malik and colleagues who found an association (Gardosi et al., 2013). Jhpiego an affiliate of Johns Hopkins University showed that, Antepartum hemorrhage increases the risk for fetal death (Smith ,2016).

According to Royal College of Obstetrics &Gynaecology, pregnancies complicated by unexplained APH are also at increased risk of adverse perinatal outcomes this was based on a meta-analysis of unexplained APH identified 10 relevant studies in the previous 38 years, with a APH having three times risk of preterm delivery, and two times risk of stillbirth (Royal College of Obstetrics & Gynaecology 2012). The pathophysiology behind APH and stillbirth is that, after detachment of the placenta, bleeding occurs thus predisposing the fetus to hypoxia then fetal death (Anderson et al., 2020). The current study had few number of cases of APH that is why it could not be possible to show association with stillbirth.

4.2.4 Strength of the study

The strength of the study includes using prospectively collected hospital based information from patients and patient‟s case note/ANC card. This provide a unique possibility to investigate the predictors of adverse pregnancy outcomes with minimal risk of selection bias and recall bias.This study was conducted in Pwani region where all post-delivery mothers, who participed in the study were contacted and interviewed by the healthcare provider, and the information of the index pregnancy and past pregnancies were collected and documented for study use.

4.2.5 Limitation of the study

The collection of primary data largely depends on the respondent‟s ability to recall and respond on past events. It is expected some postnatal mothers experienced stillbirth may fail to give some responses due to psychological trauma which can contribute to poor response of respondents. Although many aspects of stillbirth and neonatal mortality overlap, the focus of this study on stillbirth alone, without including neonatal mortality, limits the generalisability of its findings to neonatal mortality Finally, a lack of specific information on mothers‟ socioeconomic circumstances, including the mothers‟ source of income, was also an important potential limitation of this study. Controlling for husband‟s occupation and place of residence as a measure of socioeconomic.

During data collection, it was a peack period of endemic disease COVID 19, so it was difficult to make long convusation with patients therefore I fail to collect other important information concerning the predictors as it was restricted by government to maintain social distance and avoid croweding.

CHAPTER FIVE

5.0 CONCLUSION AND RECOMMENDETION

5.1 Conclusion

The purpose of the study was to assess the predictors of stillbirth among post- delivery mothers in Pwani Region.The finding of this study shows that the predictors of stillbirth includes Maternal factors (ANC visit, birth Interval, Malaria in index pregnancy, HB level,use of local herbs), fetal factors (malpresentation, cord around the neck and fetal birth weight <2.5kg or >4kg) are associated with increased risks of stillbirth and Obstetric factors are early of rupture of membrane, cord prolapse and APH. Health care professionals should be able to identify the risk and take actions promptly, however, these finding are overlapping from those reported in other study conducted in diferent settings. Stillbirth is a worrisome issue in Pwani Region as the rates is estimated to be 3.5%.

Access of targeted counselling and prevention programs may assist in improving the wellbeing of every woman of childbearing age. It is important to pay more attention to maternal influences before pregnancy to prevent the recurrence cycle of stillbirth. This mean that ANC services in Pwani needs to be strengthened so that risk factors are diagnosed early and handled appropriately. Continuous aggressive intrapartum care may be the answer to women in labor to avert stillbirths amongst this sub group.

Health care providers should take action early in cases Health care provider needs quick decision when there is inpending stillbirth.

5.2 Recommendetion

Based on the above conclusion, the followings are the recommendations. To MOHCDGEC and Regional Management Team: o Expand acceptance of safe motherhood through improving uptake of focused antenatal care among women of reproductive age and pregnant mothers. This can be done by targeting women of reproductive age in colleges, churches, and even during antenatal clinics.

49 o Empowerment Girl child to achieve gender equality in line with Sustainable Development Goal 5 will help reduce unwanted teenage pregnancy thus reduce unwanted fetal deaths since they will be able to seek medical care when required. To Institutionals: o Improve staffing; develop protocol regarding triaging and labor monitoring using partograph and the hospital to ensure availability and adequacy of equipments required for proper management of women in labor such as cardiac monitors.

5.3 Study dissemination

Results of the study will be disseminated to the University of Dodoma through College of Health, to coordinator of Nursing and Midwifery at UDOM, manager of library at UDOM, RMO at Pwani, and midwife academic journal for publication.

5.4 Suggestion for further study

A qualitative study will beneficial for the study as it will explore more information from parent feelings and health provider actual practice, and other factors may be assessed like social economical status of post-delivery mothers, cultural believes. A qualitative study will provide a more realistic information and limit biases on the factors influencing to stillbirth.

REFERENCES

Al-Riyami, Nihal, Fatma Al-Shezawi, Intisar Al-Ruheili, Tamima Al-Dughaishi, and Murtadha Al-Khabori. 2013. “Perinatal Outcome in Pregnancies with Extreme Preterm Premature Rupture of Membranes (Mid-Trimester PROM).” Sultan Qaboos University Medical Journal 13(1):51–56. Aminu et al. 2019. “Understanding Cause of Stillbirth : A Prospective Observational Multi-Country Study from Sub-Saharan Africa.” BMC Pregnancy and Childbirth 7:1–10. Aminu, M., R. Unkels, M. Mdegela, B. Utz, S. Adaji, and N. van den Broek. 2014. “Causes of and Factors Associated with Stillbirth in Low- and Middle-Income Countries: A Systematic Literature Review.” BJOG : An International Journal of Obstetrics and Gynaecology 121:141–53. Anderson, Emma, Edwin Amalraj Raja, Ashalatha Shetty, Mika Gissler, Miriam Gatt, Siladitya Bhattacharya, and Sohinee Bhattacharya. 2020. “Changing Risk Factors for Placental Abruption: A Case Crossover Study Using Routinely Collected Data from Finland, Malta and Aberdeen.” PLoS ONE 15(6):1–15. Avachat, ShubhadaSunil, DeepakB Phalke, and VaishaliD Phalke. 2015. “Risk Factors Associated with Stillbirths in the Rural Area of Western Maharashtra, India.” Archives of Medicine and Health Sciences 3(1):56. Badimsuguru, Adam Bukari, Kofi Mensah Nyarko, Edwin Andrew Afari, Samuel Oko Sackey, and Chrysantus Kubio. 2016. “Determinants of Stillbirths in Northern Ghana: A Case Control Study.” The Pan African Medical Journal 25(Supp 1):18. Bayou, Getachew, and Yifru Berhan. 2012. “Perinatal Mortality and Associated Risk Factors: A Case Control Study.” Ethiopian Journal of Health Sciences 22(3):153–62. Bhusal, Mahesh, Nirmal Gautam, Apiradee Lim, and Phattrawan Tongkumchum. 2019. “Factors Associated With Stillbirth Among Pregnant Women in Nepal.” 154–60. Bhutta, Zulfiqar A., Zohra S. Lassi, Ann Blanc, and France Donnay. 2010. “Linkages Among Reproductive Health, Maternal Health, and Perinatal Outcomes.” Seminars in Perinatology 34(6):434–45. Bottero, Julie, Harold Noe, Virginie Masse, Hugues Cordel, Hortense Kossou,

Benjamin Fayomi, Paul Ayemonna, Nadine Fievet, Achille Massougbodji, and Michel Cot. 2009. “Intermittent Treatment for the Prevention of Malaria during Pregnancy in Benin : A Randomized , Open- Label Equivalence Trial Comparing Sulfadoxine- Pyrimethamine with Mefloquine.” Journal of Infectious Diseases 200:991–1001. Christou, Aliki, Michael J. Dibley, and Camille Raynes-greenow. 2017. “Beyond Counting Stillbirths to Understanding Their Determinants in Low- and Middle- Income Countries : A Systematic Assessment of Stillbirth Data Availability in Household Surveys.” 22(3):294–311. Chuwa, Francisca S., Amasha H. Mwanamsangu, Benjamin G. Brown, Sia E. Msuya, Elizabeth E. Senkoro, Oresta P. Mnali, Festo Mazuguni, and Michael J. Mahande. 2017. “Maternal and Fetal Risk Factors for Stillbirth in Northern Tanzania: A Registry-Based Retrospective Cohort Study.” PLoS ONE 12(8):1– 10. Contag, Stephen, Clayton Brown, Sarah Crimmins, and Katherine Goetzinger. 2016. “Influence of Birthweight on the Prospective Stillbirth Risk in the Third Trimester: A Cross-Sectional Cohort Study.” American Journal of Perinatology Reports 06(03):e287–98. Devi, Kallur Sailaja, Nuzhat Aziz, Anisharamniklal Gala, Tarakeswari Surapaneni, Divya Nair H, and B. Hira. 2018. “Incidence of Stillbirths and Risk Factors at a Tertiary Perinatal Center in Southern India : Retrospective Observational Study.” International Journal of Gynecology and Reproductive Sciences 1(January 2010):14–22. Dowswell, T., G. Carroli, L. Duley, S. Gates, Gülmezoglu Am, and G. Piaggio. 2015. “Alternative versus Standard Packages of Antenatal Care for Low-Risk Pregnancy ( Review ) SUMMARY OF FINDINGS FOR THE MAIN COMPARISON.” (7). Egbe, Thomas Obinchemti, Edwin Nkwelle Ewane, and Nicholas Tendongfor. 2020. “Stillbirth Rates and Associated Risk Factors at the Buea and Limbe Regional Hospitals, Cameroon: A Case-Control Study.” BMC Pregnancy and Childbirth 20(1):1–8. Gardosi, Jason, Vichithranie Madurasinghe, Mandy Williams, Asad Malik, and André Francis. 2013. “Maternal and Fetal Risk Factors for Stillbirth: Population Based Study.” BMJ (Online) 346(7893).

Goldwater, Paul N., and Karl A. Bettelheim. 2015. “SIDS Risk Factors : Time for New Interpretations . The Role of Bacteria SIDS Risk Factors : Time for New Interpretations . The Role of Bacteria.” (March). Gross, Karin, Sandra Alba, Tracy R. Glass, Joanna A. Schellenberg, and Brigit Obrist. 2012. “Timing of Antenatal Care for Adolescent and Adult Pregnant Women in South-Eastern Tanzania.” BMC Pregnancy and Childbirth 12. Haftu, Abera, Hadgay Hagos, Mhiret Ab Mehari, and Brhane Gher. 2018. “Pregnant Women Adherence Level to Antenatal Care Visit and Its Effect on Perinatal Outcome among Mothers in Tigray Public Health Institutions, 2017: Cohort Study 11 Medical and Health Sciences 1114 Paediatrics and Reproductive Medicine 11 Medical and Heal.” BMC Research Notes 11(1):1–6. Herbert, Hadley K., Anne CC Lee, Aruna Chandran, Igor Rudan, and Abdullah H. Baqui. 2012. “Care Seeking for Neonatal Illness in Low- and Middle-Income Countries: A Systematic Review.” PLoS Medicine 9(3). Jahani, Mohammad Ali, Zahra Akbarian Rad, Masoome Naghavian, Tayebe Salmanian, and Mohsen Haghshenas Mojaveri. 2015. “Factors Affecting Stillbirth Rate in the Hospitals Affiliated to Babol University of Medical Sciences.” Iranian Journal of Neonatology 6(3):22–27. Jammeh, Abdou, Siri Vangen, and Johanne Sundby. 2010. “Stillbirths in Rural Hospitals in The Gambia: A Cross-Sectional Retrospective Study.” Obstetrics and Gynecology International 2010:1–8. Jolly, Pauline E., Nelly J. Yatich, Ellen Funkhouser, John E. Ehiri, Tsiri Agbenyega, Jonathan K. Stiles, Julian C. Rayner, Archer Turpin, William O. Ellis, Yi Jiang, Jonathan H. Williams, Evans Afriyie-Gwayu, and Timothy Phillips. 2010. “Malaria, Intestinal Helminths and Other Risk Factors for Stillbirth in Ghana.” Infectious Diseases in Obstetrics and Gynecology 2010. Joshi, Khushboo, Ruchi Saxena, Madhu Bhat, Yashpal Lomrod, and Kamala Verma. 2017. “Incidence of Cord around the Neck and Its Effects on Labour and Neonatal Outcome.” 15–18. Kc, Ashish, Viktoria Nelin, Johan Wrammert, Uwe Ewald, Ravi Vitrakoti, Geha Nath Baral, and Mats Målqvist. 2015. “Risk Factors for Antepartum Stillbirth : A Case-Control Study in Nepal.” 1–10. Kc, Ashish, Johan Wrammert, Uwe Ewald, Robert B. Clark, Jageshwor Gautam, and Gehanath Baral. 2016. Incidence of Intrapartum Stillbirth and Associated Risk

Factors in Tertiary Care Setting of Nepal : A Case-Control Study. Reproductive Health. Khanam, Rasheda, Saifuddin Ahmed, Andreea A. Creanga, Nazma Begum, Alain K. Koffi, Arif Mahmud, Heather Rosen, and Abdullah H. Baqui. 2017. “Antepartum Complications and Perinatal Mortality in Rural Bangladesh.” BMC Pregnancy and Childbirth 17(1):1–8. Kidanto, Hussein, Georgina Msemo, Donan Mmbando, Neema Rusibamayila, Hege Ersdal, and Jeffrey Perlman. 2015. “International Journal of Gynecology and Obstetrics Predisposing Factors Associated with Stillbirth in Tanzania.” International Journal of Gynecology and Obstetrics 130(1):70–73. Kupka, Roland, Tarik Kassaye, Elmar Saathoff, Ellen Hertzmark, Gernard I. Msamanga, and Wafaie W. Fawzi. 2009. “Predictors of Stillbirth among HIV- Infected Tanzanian Women.” Acta Obstetricia et Gynecologica Scandinavica 88(5):584–92. Lakshmi, Sujatha Thankappan, Uma Thankam, Preetha Jagadhamma, Anuja Ushakumari, Nirmala Chellamma, and Sankar Vaikam Hariharan. 2017. “Risk Factors for Still Birth : A Hospital Based Case Control Study.” 6(3):970–74. Lavin, T;, and R. C. Pattinson. 2017. “Does Antenatal Care Timing Influence Stillbirth Risk in the Third Trimester ? A Secondary Analysis of Perinatal Death Audit Data in South Africa.” International Journal of Obstetrics and Gynecology 140–47. Lavin, T., and R. C. Pattinson. 2018. “Does Antenatal Care Timing Influence Stillbirth Risk in the Third Trimester? A Secondary Analysis of Perinatal Death Audit Data in South Africa.” BJOG: An International Journal of Obstetrics and Gynaecology 125(2):140–47. Lawn, Joy E., Hannah Blencowe, Robert Pattinson, Simon Cousens, Rajesh Kumar, Ibinabo Ibiebele, Jason Gardosi, Louise T. Day, and Cynthia Stanton. 2011. “Stillbirths: Where? When? Why? How to Make the Data Count?” The Lancet 377(9775):1448–63. Liu, Li-chun, Yu-chi Wang, Mu-hsien Yu, and Her-young Su. 2014. “Taiwanese Journal of Obstetrics & Gynecology Major Risk Factors for Stillbirth in Different Trimesters of Pregnancy d A Systematic Review.” Taiwanese Journal of Obstetrics & Gynecology 53(2):141–45. Maaløe, Nanna, Natasha Housseine, Ib Christian Bygbjerg, Tarek Meguid, and

Rashid Saleh Khamis. 2016. “Stillbirths and Quality of Care during Labour at the Low Resource Referral Hospital of Zanzibar : A Case-Control Study.” BMC Pregnancy and Childbirth 1–12. Mace, Kimberly E., Victor Chalwe, Bonnie L. Katalenich, Michael Nambozi, Luamba Mubikayi, Chikuli K. Mulele, Ryan E. Wiegand, Scott J. Filler, Mulakwa Kamuliwo, Allen S. Craig, and Kathrine R. Tan. 2015. “Evaluation of Sulphadoxine-Pyrimethamine for Intermittent Preventive Treatment of Malaria in Pregnancy: A Retrospective Birth Outcomes Study in Mansa, Zambia.” Malaria Journal 14(1):1–11. Malacova, E., A. Regan, N. Nassar, C. Raynes-Greenow, H. Leonard, R. Srinivasjois, A. W Shand, T. Lavin, and G. Pereira. 2018. “Risk of Stillbirth, Preterm Delivery, and Fetal Growth Restriction Following Exposure in a Previous Birth: Systematic Review and Meta-Analysis.” BJOG: An International Journal of Obstetrics and Gynaecology 125(2):183–92. Mbwanji. 2010. “Prevalence of Herbal Medicine Use and Associated Factors among Pregnant Women Attending Antenatal Clinic at Mbeya Refferal Hospital in 2010.” McClure, Dudley, Reddy &. Goldenberg. 2010. “Infectious Causes of Stillbirth: A Clinical Perspective.” Bone 23(1):1–7. McClure, E. M., A. Garces, S. Saleem, J. L. Moore, C. L. Bose, F. Esamai, S. S. Goudar, E. Chomba, M. Mwenechanya, O. Pasha, A. Tshefu, A. Patel, S. M. Dhaded, C. Tenge, I. Marete, M. Bauserman, S. Sunder, B. S. Kodkany, W. A. Carlo, R. J. Derman, P. L. Hibberd, E. A. Liechty, K. M. Hambidge, N. F. Krebs, M. Koso-Thomas, M. Miodovnik, D. D. Wallace, and R. L. Goldenberg. 2018. “Global Network for Women‟s and Children‟s Health Research: Probable Causes of Stillbirth in Low- and Middle-Income Countries Using a Prospectively Defined Classification System.” BJOG: An International Journal of Obstetrics and Gynaecology 125(2):131–38. Mcclure, Elizabeth M., and Robert L. Goldenberg. 2014. “Factors and Prevention Strategies.” Maternal Fetal Neonatal Med 22(3):183–90. Minerva Kyei-Nimakoh. 2017. Management and Referral of Obstetric Complications : A Study in the Upper East Region of Ghana. Moore, Kerryn A., Julie A. Simpson, Michelle J. L. Scoullar, Rose McGready, and Freya J. I. Fowkes. 2017. “Quantification of the Association between Malaria in

Pregnancy and Stillbirth: A Systematic Review and Meta-Analysis.” The Lancet Global Health 5(11):e1101–12. Mpembeni, R;Jonathan, R;Mughamba, J. 2014. “Perinatal Mortality and Associated Factors Among Deliveries in Three Municipal Hospitals of Dar Es.” 1(4):1–7. Muniro, Zainab, Clifford Silver Tarimo, Michael J. Mahande, Eusebious Maro, and Bariki McHome. 2019. “Grand Multiparity as a Predictor of Adverse Pregnancy Outcome among Women Who Delivered at a Tertiary Hospital in Northern Tanzania.” BMC Pregnancy and Childbirth 19(1). Nahar, Shamsun, Atiya Rahman, and Hashima E. Nasreen. 2013. “Factors Influencing Stillbirth in Bangladesh: A Casecontrol Study.” Paediatric and Perinatal Epidemiology 27(2):158–64. Nair, Manisha, David Churchill, Susan Robinson, Cathy Nelson-Piercy, Simon J. Stanworth, and Marian Knight. 2017. “Association between Maternal Haemoglobin and Stillbirth: A Cohort Study among a Multi-Ethnic Population in England.” British Journal of Haematology 179(5):829–37. National Bureau of Statistics [NBS], 2015/16). n.d. Tanzania2015-16 Demographic and Health Survey and Malaria Indicator Survey. Newtonraj, Ariarathinam, Manmeet Kaur, Madhu Gupta, and Rajesh Kumar. 2017. “Level , Causes , and Risk Factors of Stillbirth : A Population-Based Case Control Study From.” 1–9. Nieminen, Anna Lena, Bodil Mannevaara, and Lisbeth Fagerström. 2011. “Advanced Practice Nurses‟ Scope of Practice: A Qualitative Study of Advanced Clinical Competencies.” Scandinavian Journal of Caring Sciences 25(4):661–70. Orobaton, Nosa, Anne M. Austin, Dele Abegunde, Mohammed Ibrahim, Zainab Mohammed, Jumare Abdul Azeez, Hakeem Ganiyu, Zwalle Nanbol, Bolaji Fapohunda, and Katherine Beal. 2016. “Scaling ‑ up the Use of Sulfadoxine ‑ Pyrimethamine for the Preventive Treatment of Malaria in Pregnancy : Results and Lessons on Scalability , Costs and Programme Impact from Three Local Government Areas in Sokoto State , Nigeria.” Malaria Journal 1–24. Peesay, Morarji. 2012. “Cord around the Neck Syndrome.” BMC Pregnancy and Childbirth 12(Suppl 1):A6. Peesay, Morarji. 2017. “Nuchal Cord and Its Implications.” Maternal Health, Neonatology and Perinatology 3(1):1–11.

Plotkin, Marya, Dunstan Bishanga, Hussein Kidanto, Mary Carol Jennings, Jim Ricca, Amasha Mwanamsangu, Gaudiosa Tibaijuka, Ruth Lemwayi, Benny Ngereza, Mary Drake, Jeremie Zougrana, Neena Khadka, James A. Litch, and Barbara Rawlins. 2018. “Tracking Facility-Based Perinatal Deaths in Tanzania: Results from an Indicator Validation Assessment.” PLoS ONE 13(7). Rovereto, Ospedale, Anna Lavezzi, Gianfranco Jorizzo, Teresa Pusiol Ospedale, and Stefano Ferrero. 2019. “Sudden Intrauterine Unexplained Death : Time to Adopt Uniform Dostmortem Investigative Guidelines ?” BMC Pregnancy and Childbirth 1. Royal College of Obstetrics &Gynaecology. 2012. Antepartum Haemorrhage ( APH ). Sayed Ahmed, Waleed Ali, and Mostafa Ahmed Hamdy. 2018. “Optimal Management of Umbilical Cord ProlapseSayed Ahmed, W. A., & Hamdy, M. A. (2018). Optimal Management of Umbilical Cord Prolapse. International Journal of Women‟s Health, 10, 459–465. Https://Doi.Org/10.2147/IJWH.S130879.” International Journal of Women’s Health 10:459–65. Schreiber, Hanoch, Yair Daikan, Nissim Arbib, Ofer Markovitch, Arie Berkovitz, and Tal Biron-Shental. 2018. “127: Multiple Nuchal Cord Loops and Neonatal Outcomes.” American Journal of Obstetrics and Gynecology 218(1):S91. Seale, Anna C., Hannah Blencowe, Fiorella Bianchi-Jassir, Nicholas Embleton, Quique Bassat, Jaume Ordi, Clara MenCrossed, Clare Cutland, Carmen Briner, James A. Berkley, Joy E. Lawn, Carol J. Baker, Linda Bartlett, Michael G. Gravett, Paul T. Heath, Margaret Ip, Kirsty Le Doare, Craig E. Rubens, Samir K. Saha, Stephanie Schrag, Ajoke Sobanjo Ter Meulen, Johan Vekemans, and Shabir A. Madhi. 2017. “Stillbirth with Group B Streptococcus Disease Worldwide: Systematic Review and Meta-Analyses.” Clinical Infectious Diseases 65. Smith, Jeffrey. 2016. Antepartum Hemorrhage : A Risk Factor for PTB / LBW and Newborn Mortality Obstetric Conditions That Lead to Preterm Birth. Stormdal Bring, Hanna, Ingela A. Hulthén Varli, Marius Kublickas, Nikos Papadogiannakis, and Karin Pettersson. 2014. “Causes of Stillbirth at Different Gestational Ages in Singleton Pregnancies.” Acta Obstetricia et Gynecologica Scandinavica 93(1):86–92.

Swaminathan, Akshay, Deshayne B. Fell, Annette Regan, Mark Walker, and Daniel J. Corsi. 2020. “Association between Interpregnancy Interval and Subsequent Stillbirth in 58 Low-Income and Middle-Income Countries: A Retrospective Analysis Using Demographic and Health Surveys.” The Lancet Global Health 8(1):e113–22. Taha, Zainab, Ahmed Ali Hassan, Ludmilla Wikkeling-Scott, and Dimitrios Papandreou. 2020. “Factors Associated with Preterm Birth and Low Birth Weight in Abu Dhabi, The United Arab Emirates.” International Journal of Environmental Research and Public Health 17(4). Tavares, Fernanda, Da Silva, Bernard Gonik, Mark Mcmillan, Cheryl Keech, Stephanie Dellicour, Shraddha Bhange, Mihaela Tila, Diana M. Harper, Charles Woods, Alison Tse, Sonali Kochhar, Flor M. Munoz, The Brighton, Collaboration Stillbirth, and Working Group. 2016. “Stillbirth:Case Definition and Guidelines for Data Collection, Analysis, and Presentation of Maternal Immunization Safety Data.” 1–12. Tilahun, Dejene, and Tsion Assefa. 2017. “Incidence and Determinants of Stillbirth among Women Who Gave Birth in Jimma University Specialized Hospital, Ethiopia.” Pan African Medical Journal 28:1–11. Warland, Jane, and Edwin A. Mitchell. 2014. “A Triple Risk Model for Unexplained Late Stillbirth.” BMC Pregnancy and Childbirth 14(1):1–6. WHO. 2012. “WHA Global Nutrition Targets 2025: Low Birth Weight Policy Brief.” W.H.O Publication 1–7. Wijs, L. A., De Graaff E. C, S. Leemaqz, and G. A. Dekker. 2016. “ST AC.” The Journal of Maternal-Fetal & Neonatal Medicine 0(0):000. Zakaria, Pagwuni, and Latifatu Abubakar. 2018. “Herbal Medicine Usage before and during Pregnancy – a Study in Northern Ghana.” 11(4).

Appendix 1 : Consent form (English)

Title of Study: Assessing Predictors of Stillbirth among post delivery women in Pwani Region

Principal Investigator: Predicanda Mzurikwao Simtowe

Qualification: Registered Nursing Officer II, Postgraduate student schooling Master of Science in midwifery admitted at the University of Dodoma Collage Health Sciences department of Nursing and Midwifery.

Address: Kibaha college of Health and Allied Sciences Box 30028 Kibaha

Introduction

The number of children we lose during pregnancy and at child birth has been increasing in recent years and a concern to health authorities as well as the people in the Pwani region. This study seeks to understand how pregnant women appreciate the role played by health service delivery and the effects of our social lives on the problem. You are being invited to participate in the study because I understand you know the importance of your health, especially during pregnancy and you also delivered your last pregnancy at Hospital. I will ask you to consider taking part in the study. If you agree to participate in this study, I will take your address and you will choose a comfortable time and comfortable place to come to talk to you about the problem happens, during our talk I will ask you a few questions centered on your last pregnancy and child birth. This will take about 20 minutes of your time.

You will also give me your Maternal Health Record book you used in your last pregnancy to record what was documented. However, if you do not have one I will like to ask you some questions concerning your last pregnancy to enable me get the information. If you agree to participate, you be among 64 women who will also be participating in this study in the Pwani Region.

Participating in this study is entirely voluntary. You have the right to refuse to participate and this will not affect your rights in anyway, especially to your health care. You are also having freedom to withdraw from this study at any stage of your participation. I will like to see you participate to end of the study.

Purpose of the Study

The study seeks to provide evidence based information on strategies to reduce the rate of stillbirths in Pwani Region and lay in knowledge to the very few published literatures on the predictors of stillbirths in Pwani region; thus, to develop new. Further, the findings of the study will form a basis for the amendment of the existing national policy to reduce the prevalence of stillbirths and as well raise the community awareness on prevention of stillbirths among the community.

Ultimately, this research may be published as a journal article.

Benefits/ Risks/Discomforts of Being in this Study

There are no direct benefits or risks in participating. You will not be paid or compensated for your participation. However, the information that the study will come out with, will help us to understand the factors and circumstances associated with the increased stillbirths in the Pwani Region. The questions are not very sensitive. However, you may feel uncomfortable answering some of them and you can choose not to answer them

Confidentiality

All the information collected from you will be treated strictly confidential and will be used for the intended purpose only. You will not be identified by name in any dissemination reports or publications resulting from this study.

Right to Refuse or Withdraw

The decision to participate in this study is entirely up to you. You may refuse to take part in the study at any time without affecting your relationship with the investigators of this study or any Hospital where you receive services.

You have the right not to answer any single question, as well as to withdraw completely from the study at any point during the process.

Right to Ask Questions and Report Concerns

You have the right to ask questions about this research study and to have those questions answered by me before, during or after the research. If you have any further questions about the study, at any time feel free to contact me, Predicanda Mzurikwao Simtowe at [email protected] or by telephone at +255768146620. If you like, a summary of the results of the study will be sent to you.

If you have any other concerns about your rights as a research participant that has not been answered by the investigators, you may contact Dr. Faustine Bee Deputy Vice Chancellor Academic, Research and Consultant, P. O. Box 259, Dodoma, Tanzania, Telephone number +2550262310301.

PARTICIPANT CONSENT

I have been adequately informed about the purpose, procedures, potential risks and benefits of this study. I have had the opportunity to ask questions and any questions that I have asked have been answered to my satisfaction. I know that I can refuse to participate in this study without any loss of benefit to which I would have otherwise been entitled. I understand that if I agree to participate I can withdraw my consent at any time without losing any benefits or services to which I am entitled. I understand that the information collected will be treated confidentially. I freely agree to participate in this study.

ID of Participant…………………………………Date………………………………

Thumb Print…………………………………….Date……………………………….

Appendix 2: Form Ya Ridhaa Ya Utafiti wa Kuangalia Viashiria Vya Watoto Wachanga Kuzaliwa Wafu (Kiswahili)

Utangulizi

Idadi ya watoto wanaopoteza maisha wakati wa ujauzito na wakati wakujifungua imekuwa ikiongezeka katika miaka ya hivi karibuni na hii imepelekea kuleta sintofahamu kwa mamlaka na watu wa mkoa wa Pwani.Utafiti huu una lengo la kubaini athari za jamii na majukumu yawatoa huduma katika kutokomeza hili tatizo kwa wanawake wajawazito.

Napenda kuchukua fursa hii kukukaribisha wewe katika kushiriki katika tafiti hii kwani ni mtu muhimu sana ili tuweze kuboresha hudama za mama na mtoto. Kama utapenda kushiriki katika tafiti hii, nitaomba namba yako na ili tupange ni muda gani na sehemu gani tunaweza mimi na wewe kukaa na kuzungumza kuhusu tatizo hili. Nitakuuliza maswali machache sana kwa muda usiozidi dakika 20 tu. Na katika maongezi yetu nitauliza kuhusu maswala yanayohusu ujauzito wako wa mwisho.

Pia nitaomba unikabidhi kadi yako ya mahudhurio ya kliniki uliyoitumia katika ujauzito wako huu. Hata kama hutakuwa na hiyo kadi au kitabu chako, bado nitahitaji kujua kwa undani kuhusu historia ya ujauzito wako wa mwisho. Nitashukuru sana kukubali kushirikiana na katika utafiti huu na utakuwa kati ya kina mama 195 waliopata bahati ya kuwezesha huu utafiti katika mkoa wa Pwani.

Tambua hulazimishwi kushiriki katika huu utafiti na una uhuru wakushiriki au kujitoa wakati wowote ule unapoona inakubidi kufanya hivyo. Hata hivyo ningefurahi kuona unashiriki mpaka mwisho wa tafiti hii.

Lengo la utafiti

Utafiti utawezesha kuonyesha ushahidi wa mikakati ya kupunguza ukubwa wa tatizo la watoto kuzaliwa wafu katika mkoa wa Pwani. Pia matokeo ya utafiti yatatumika kama msingi wa kuboresha sera ya Taifa ya Afya ili kupanua uwelewa wa wananchi na jamii nzima kuhusu madhara ya tokanayo na kujifungua watoto wafu.

Mwishowe, utafiti huu unaweza kuchapishwa kama nakala ya jarida.

Faida / Hatari / Adha kwa kushiriki katika Utafiti huu

Hakuna faida za moja kwa moja au hatari katika kushiriki. Hautalipwa au kulipwa fidia kwa ushiriki wako. Walakini, habari ambayo utafiti utapata kutoka kwako, itatusaidia kuelewa sababu na hali zinazohusiana na kuongezeka kwa watoto wachanga kuzaliwa wafu katika Mkoa wa Pwani. Maswali sio nyeti sana. Walakini, unaweza kujisikia vibaya kujibu baadhi ya maswali na unaweza kuchagua kutoyajibu.

Usiri

Habari yote iliyopatikana kutoka kwako itakuwa siri kati yako na mtoa huduma na itatumika kwa kusudi lililokusudiwa tu. Hautatambuliwa kwa jina katika ripoti yoyote ya usambazaji au machapisho yanayotokana na utafiti huu.

Haki ya Kukataa au Kuachana na utafiti

Uamuzi wa kushiriki katika utafiti huu ni ihali yako kabisa. Unaweza kukataa kushiriki katika utafiti wakati wowote bila kuathiri uhusiano wako na wachunguzi wa utafiti huu au Hospitali yoyote ambayo unapata huduma.

Una haki ya kukataa kujibu maswali, na pia kujiondoa kutoka kwenye utafiti wakati wowote wa mchakato.

Haki ya Kuuliza Maswali na kueleza wasiwasi wowote wa utafiti

Una haki ya kuuliza maswali juu ya utafiti huu na kuwa maswali hayo yatajibiwa na mimi kabla, wakati au baada ya utafiti. Ikiwa una maswali yoyote juu ya utafiti, wakati wowote jisikie huru kuwasiliana nami, Predicanda Mzurikwao Simtowe kwa barua pepe [email protected] au kwa simu kwa +255768146620. Ikiwa unapenda, muhtasari wa matokeo ya utafiti utatumiwa.

Ikiwa una wasiwasi wowote kuhusu haki yako kama mshiriki wa utafiti ambao haujajibiwa na wachunguzi, unaweza kuwasiliana na Dr.Faustine Bee Naibu Msaidizi wa Chansela wa Taaluma, Utafiti na Mshauri, PO Box 259, Dodoma, Tanzania, Namba ya simu +2550262310301

Ridhaa ya mshiriki

Nimeelimishwa vya kutosha juu ya kusudi, taratibu, hatari zinazoweza kutokea na faida za utafiti huu. Nimepata nafasi ya kuuliza maswali na maswali yoyote ambayo nimeuliza yamejibiwa na nimeridhika na majibu niliyopewa. Ninajua kuwa ninaweza

63 kukataa kushiriki katika utafiti huu bila kupoteza faida yoyote ambayo ningekuwa na haki. Ninaelewa kuwa ikiwa ninakubali kushiriki naweza kuondoa idhini yangu wakati wowote bila kupoteza faida yoyote na huduma ambazo ninastahili. Ninaelewa kuwa habari iliyokusanywa itatunzwa kwa usiri mkubwa. Nakubali kwa ihali yangu mwenyewe bila kushurutishwa kushiriki katika utafiti huu.

Kitambulisho cha Mshiriki………………………… Tarehe …………………………

Dole gumba ……………………………………. Tarehe …………………………….

Appendix 3: Questionnaire (ENGLISH)

Study title: predictors of stillbirths among post delivery mothers in Pwani region

Record ID …………………………………………..

Interviewer ID (District)……………………………

Date of completion of the form: -- -- ∕ -- -- /------.

The questions below are in four sections. Please record the data as per question in the space or options provided under various sections

Socio demographic

1. Maternal age (years) at delivery …………………………………..

2. Place of residence (Village/District)……………………………….

3. Tribe of the mother………………………………………

4. Height (cm) of the mother (as recorded in the Maternal Health Record book or ANC card). ………………………………………….…

5. Weight (kg) of the mother at: Registration ……………

6. Weight (kg) of the mother on admission to labour ward …………………

7. Maternal marital status.

a. Married

b. Single

8. Residential area of the mother.

a. Urban

b. Rural

9. Maternal educational level.

a. No formal education b. Primary c. Secondary d. Tertiary

10. Employment status of the mother.

a. Self employed

b. Formal (Public and other sectors)

11. Do mother drink alcohol during index pregnancy?

a. Yes

b. No

12. Do mother smoke during index pregnancy?

a. Yes

b. No

Maternal factors

13. Gestation of index pregnancy at first antenatal clinic visit.

……………………………………………....

14. Number of visits to antenatal clinic in index pregnancy.

………………… (Count record from Maternal Health Record book or ANC card)

15. Antenatal folic acid taken.

a. Yes

b. No

16. Parity of the woman in index pregnancy.

…………………….

17. Outcome of her last delivery was is it live

a. Yes

b. No

18. History of previous stillbirth?

a. Yes

b. No

19. Birth interval of last delivery and index pregnancy. Was it more than 24 months?

a. Yes

b. No

20. Gestation of pregnancy (in completed weeks relative to last menstrual period as recorded in Maternal Health Record book or maternity notes or ANC card). ……………………………………..

21. What was the fundal height during admission to labour ward?......

22. Used or taken local herbs/ potion (s) in index pregnancy?

a. Yes

b. No

23. VDRL status.

a. Reactive

b. None reactive

24. If reactive, treated? (observe maternal treatment notes)

a. Yes

b. No

25. HIV status

a. Positive

b. Negative

26. If Positive for how long is she known to be Positive

………………………………………….

27. If positive, is she on ART

a. Yes

b. No

28. If yes for how long is she on ART

……………………………..

29. Hemoglobin level (g/dl) on first antenatal registration of index pregnancy

……………………………………….

30. Hemoglobin level (g/dl) on admission to labour ward

………………………………………………

31. What is the blood group of the mother?

……………………………………………………..

32. Diagnosis of malaria in index pregnancy?

a. Yes

b. No

33. Sulfadoxine pyrimethamine doses received during antenatal care in index pregnancy

a. Less or equal 2 doses

b. 2-4 doses

34. If not received any/ less what was the reason………………………….

35. Was the mother diabetic?

a. Yes

b. No

36. If yes when did the diabetes diagnosed?

a. Before pregnancy

b. During pregnancy

37. If yes, is she on any management

a. Yes

b. No

38. Did the management of diabetes start during pregnancy?

a. Yes

b. No

39. Urinalysis.

Sugar ………….. mmol / dl Protein: ……….…. (Record positive/negative or as documented in laboratory results)

40. Systolic blood pressure (mm/Hg).

First registration at ANC……… …………………………….

And on admission to labour ward……………… ……….. …….

41. Diastolic blood pressure (mm/Hg) at

First registration at ANC…………………………….

On admission to labour ward……………..

42. History of admission in early pregnancy?

a. Yes

b. No,

43. If yes write diagnosis ………………………………………

Fetal factors

44. Fetal presentation (as recorded in maternity notes/ANC card)

a. Cephalic (Vertex)

b. Breech

c. Transverse

45. Weight (kg) of baby at birth…………………………..gm

46. Was the child a single or multiple births?

a. Singleton

b. Multiple

47. What was the birth order of the child that died?

a. First

b. Second

c. Third or higher 3

48. Did the baby stop moving in the womb?

a. Yes

b. No

49. Did the baby stop moving in the womb during labour?

a. Yes

b. No

50. During labor did the midwife listen to fetal heart rate?

a. Yes b. No

51. Were the fetal heart present?

a. Yes b. No

52. Were there signs of injury or broken bones?

a. Yes b. No

53. Did the baby have any malformation?

a. Yes b. No

54. What type of malformation was found on by after birth?( Mention )

…………………………………………………..

55. Did the baby have cord around the neck after delivery?

a. Yes

b. No

56. After birth what was the color of baby?

a. Normal (pink) b. pale c. blue

57. Did the baby assisted to breathe?

a. Yes b. No

58. Did the baby ever cry after birth even little?

a. Yes b. No

59. Did the baby ever move, even a little?

a. Yes b. No

60. If the baby did move, or cry, did the baby born dead?

a. Yes b. No

Obstetric factors

61. Was there any severe bleeding per vagina before labor starts?

a. Yes b. No

62. Did the cord prolapsed during labor?

a. Yes b. No

63. What was the method of delivery?

a. NVD b. C/S c. Vacuum assisted delivery

64. Admission status to the facility for delivery

a. Referral from other facility b. Admission from home

65. Did health provider use cartography to monitor progress of labour

a. Yes b. No

66. At what time did the membrane rupture?

a. Before labor started b. During labor

67. How many hours was the baby born after rupture of membrane?

a. Less than 24 hours b. 24 hours or more

68 Did the liquor foul smelling?

a. Yes b. No

Appendix 4: Dodoso (Kiswahili)

Dodoso la utafiti la kuangalia viashiria sababishi vya watoto wachanga kuzaliwa wafu, kwa mama aliyezalia Hospitali katika mkoa wa Pwani.

Namba ya utambulisho wa mama……………………….

Kituo………………………..Wilaya……………………………...

Tarehe ya mahojiano…………………………………………..

Maswali yafuatayo yako katika vipengele vinne. Tafadhari jaza uchunguzi kulingana na swali katika nafasi iliyoachwa wazi au chagua jibu sahihi kati ya majibu yaliyoorodheshwa

Sehemu ya kwanza

Taarifa za Kidemografia

1. Umri wa mama (katika miaka)………………………………… 2. Mahari anapoishi………………………………………………. 3. Kabila la mama…………………………………………………… 4. Urefu wa mama (km ulivyorekodiwa kwenye kadi yake ya kliniki)………………… 5. Uzito wa mama wakati anaanza kliniki ya uzazi……………………………….. 6. Uzito wa mama alipofika wiki 36 za ujauzito………………………………….

7. Hali ya ndoa ya mama

a. Ameolewa b. Hajaolewa c. Ameachika d. Mjane

8. Sehemu mama anayoishi kwa sasa

a. Mjini b. Kijijini

9. Elimu ya mama

a. Hajasoma b. Elimu ya msingi c. Elimu ya sekondari d. Elimu ya chuo

10. Mama anafanya kazi gani

a. Mkulima b. Amejiajiri c. Ameajiriwa (Ajira rasmi)

11. Mama alikuwa anakunywa pombe wakati wa ujauzito huu

a. Ndio b. Hapana

12. Je mama alikuwa anavuta sigara wakati wa ujauzito huu.

a. Ndio b. Hapana

Sehemu ya pili

Viashiria vya mama

13. Umri wa mimba siku ya kwanza kuhudhuria kliniki……………………………………....

14. Idadi ya siku alizohudhuria kliniki wakati wa ujauzito……………………….

(Soma kutoka katika kadi ya Klinik)

15. Kipindi cha ujauzito ulitumia folic acid?

a. Ndio b. Hapana

16. Uzazi huu ni wa ngapi……………………………………….

17. Uzazi wa mwisho kabla ya huu ulikuwa hai?

a. Ndio

b. Hapana

18. Una historia ya watoto wafu kabla ya kuzaliwa?

a. Ndio b. Hapana

19. Muda gani umepita toka mimba iliyopita na hii ya sasa je ni Zaidi ya miezi 24?

a. Ndio b. Hapana

20. Umri wa mimba hii katika wiki kamili toka ulipoona damu ya enzi ya mwisho? ......

(Angalia katika kadi ya klinik)

21. Kimo cha mimba alipokuja labor?

22. Je katika kipindi cha ujauzito mama amewahi kutumia dawa za kienyeji au dawambadala?

a. Ndio b. Hapana

23. Hali ya maambukizi ya Kaswende

a. Ipo b. Haipo

24. Kama ipo

a. Ilitibiwa b. Haikutibiwa (angalia katika kadi ya kliniki)

25. Hali ya maambukizi ya VVU

a. Ipo b. Haipo

26. Kama ipo ni muda gani tangu agundulike ……………………………….

27. Kama ipo anatumia dawa

a. Ndio b. Hapana

28. Kama anatumia dawa ni muda gani tangu aanze dawa……………………………

29. Kiwango cha damu ilikuwa ngapi alipoanza klinik……………………………….

30. Kiwango cha damu akiwana wiki 36 ………………………..

31. Group la damu ya mama ni lipi? ......

32. Katika kipindi cha ujauzito amewahi kugundulika na Malaria?

a. Ndio b. Hapana

33. Katika kipindi cha ujauzito alitumia kinga ya malaria? (sulfadoxine pyrimethamine)

a. Dozi moja b. Dozi mbili c. Dozi tatu d. Hakutumia 34. Kama hajatumia au ametumia pungufu ni kwa nini?...... 35. Mama anakisukari? a. Ndio b.Hapana c. Hajui 36. Kama ndio aligunduliwa lini kuwa na kisukari? a. Kabla ya mimba b. Wakati wa mimba hii 37. Kama ndio, anatumia matibabu? a. Ndio b. Hapana 38. Ni wakati gani alianza matibabu ya kutibu ugonjwa wa sukari……………………

39. Aliwahi kupima mkojo?

Kiwango cha Sukari kwenye mkojo ……………

Kiwango cha protini kwenye mkojo…………… (Andika -ve/ve+ au iliyoandikwa katika kadi ya klinik)

40. Kipimo cha juu cha msukumo wa damu (systolic BP)

wakati unaanza kliniki……………………………………

wakati unalazwa labour ward…………………………….

41. Kipimo cha chini cha msukumo wa damu (diastolicBP)

wakati unaanza Cliniki………………………………

wakati unalazwa labour wodi……………….………

42. Umewahi kulazwa wakati wa ujauzito?

a. Ndio b. Hapana

43. Kama ndio ulikuwa unaumwa nini? (Taja)......

Sehemu ya tatu

Viashiria vya mtoto

44. Mtoto alitanguliza sehemu gani katika ulalo wake (soma katika kadi)

a. Kichwa b. Matako c. Mabega

45. Uzito wa mtoto alipozaliwa (kg)………………………………….

46. Uzazi ulikuwa wa aina gani?

a. Mtoto mmoja b. Watoto wawili au zaidi

47. Mtoto aliyezaliwa alikuwa wa ngapi?

a. Kwanza b. Wa pili c. Wa tatu

48. Mtoto aliacha kucheza tumboni

a. Ndio b. Hapana

49. Ni wakati gani alipoacha kucheza

a. Kabla ya uchungu b. Wakati wa uchungu

50. Mkunga alisikiliza mapigo ya mtoto wakati wa uchungu

a. Ndio b. Hapana

51. Mapigo ya mtoto yalikuwapo?

a. Ndio b. Hapana

52. Mtoto alipozaliwa kulikuwa na dalili ya kuumia au kuvunjika mfupa wowote?

a. Ndio b. Hapana

53. Je mtoto alizaliwa na ulemavu wowote?

a. Ndio

b. Hapana

54. Kama ndio, ni ulemavu aina gani? taja......

55. Je motto alipozaliwa alikuwa na kitovu kimemzunguka shingoni a. Ndio b.Hapana

56. Mtoto alipozaliwa alikuwa na rangi gani?

a. Kawaida( Pinki) b. Mpauko c. Kibluu

57. Mtoto alipozaliwa alisaidiwa kupumua?

a. Ndio b. Hapana

58. Mtoto alilia angalau kidogo baada ya kuzaliwa?

a. Ndio b. Hapana

59. Mtoto alipozaliwa aliweza kuchezesh viungo vyake angalau kidogo?

a. Ndio b. Hapana

60. Mtoto hakucheza wala kulia, je alizaliwa mfu?

a. Ndio b. Hapana

Sehemu ya nne

Viashiria vya Kiobstetric

61. Kutokwa na damu nyingi ukeni kabla ya uchungu?

a. Ndio b. Hapana

62. Kutangulia kitovu cha mtoto wakati wa uchungu?

a. Ndio b. Hapana

63. Njia ya kujifungulia

a. Kawaida b. Kwa upasuaji c. Kusaidia kuvuta mtoto

64. Hali ya kulazwa katika kituo kwa ajili ya kujifungua

a. Ametokea kituo kingine cha afya b. Amekuja toka nyumbani moja kwa moja

65. Wakati wauchungu Patographi ilitumika kuangalia maendeleo ya uchungu?

a. Ndio b. Hapana

66. Wakati gani chupa ilipasuka

a. Kabla ya uchungu b. Wakati wa uchungu

67. Ni masaa mangapi yalimepita toka chupa ipasuke mpaka kuzaliwa mtoto?

a. Chini ya masaa 24 b. Zaidi ya masaa 24

68. Chupa ilipopasuka maji yake yalikuwa yananuka vibaya?

a. Ndio b. Hapana

Appendix 5: Letter for Ethical clearance from Dodoma University bord of Research

Appendix 6: Request for research clearance

Appendix 7: Letter from Regional Administrative Secretary (RAS) for permition to conduct research in Pwani region